DAVF is a rare type of acquired vascular malformation of the intracranial venous system. The DAVF can occur anywhere within dura maters, and most of them are located at cavernous and transverse-sigmoid sinuses. Symptoms and signs of DAVF depend on its draining patterns. Although the pathophysiology of DAVF remains controversial, it has been suggested that intracranial venous hypertension represents one key factor in the etiology of DAVF [3, 4]. The natural history and therapeutic indications of DAVF are strongly correlated with their venous draining pattern, especially the presence of reflux into pial veins [5]. The Borden classification and Cognard classification, which are based on the characteristics of draining veins, represent the two most widely used systems. Low-grade fistulas (Borden I; Cognard I, IIa) are considered begin, and aggressive symptoms such as intracranial hemorrhage, intracranial hypertension, focal neurologic deficits, and seizures are found more commonly with higher-grade lesions [6]. Tentorial DAVFs, accounting for almost 4–12% of all DAVFs [7], are often associated with more aggressive neurological behaviors [8].
CCF is defined as abnormal communication between carotid arteries and the cavernous sinus, while it usually presents with ocular and orbital symptoms [9]. The clinical manifestations of DAVF around the cavernous sinus or other types of anterior cranial fossa DAVF with anterior venous drainage could be similar to those of CCF. However, tentorial DAVF with posterior drainage seldom presents with ocular symptoms initially.
For falcotentorial DAVF, a kind of tentorial DAVF, the most common draining veins are the straight sinus, vein of Galen and torcular [10]. In this case, we reported a rare case manifested with ophthalmic complaints caused by a falcotentorial DAVF due to its posterior-to-anterior draining pattern, which caused left-side increased intraocular pressure. It is difficult to promptly diagnose tentorial DAVF causing ocular symptoms at the very beginning of clinical practice.
The goal of treatment is complete and permanent obliteration of abnormal arteriovenous shunts. Endovascular embolization (i.e., transarterial, transvenous, and direct cavernous sinus routes) with embolic agents is proven to be safe and effective and has been extensively used in clinical practice [11,12,13]. In this case, the fistula was successfully occluded by the transarterial approach. Transvenous embolization is feasible for high-flow fistulas or cases with multiple, small, and tortuous feeders. In addition, open surgery and radiosurgery are alternative options if endovascular therapy is exhausted. Owing to the complex vascular anatomy, preoperative angiographic evaluation is essential before surgical and endovascular treatment. The different therapeutic strategies can be used based on the angioarchitecture, clinical presentation, location, and operator preference.