Clipping of High-Risk Dural Arteriovenous Fistula of the Posterior Fossa: 3-Dimensional Operative Video

Roberto Rodriguez Rubio; Ricky Chae; W Caleb Rutledge; Alex De Vilalta; Ioannis Kournoutas; Ethan Winkler; Adib A Abla

doi:10.1016/j.wneu.2019.03.101

Clipping of High-Risk Dural Arteriovenous Fistula of the Posterior Fossa: 3-Dimensional Operative Video

World Neurosurg. 2019 Jun:126:413. doi: 10.1016/j.wneu.2019.03.101. Epub 2019 Mar 19.

Authors

Roberto Rodriguez Rubio¹, Ricky Chae², W Caleb Rutledge³, Alex De Vilalta², Ioannis Kournoutas², Ethan Winkler³, Adib A Abla⁴

Affiliations

¹ Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, California, USA.
² Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA.
³ Department of Neurological Surgery, University of California, San Francisco, California, USA.
⁴ Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, California, USA. Electronic address: adib.abla@ucsf.edu.

PMID: 30902767
DOI: 10.1016/j.wneu.2019.03.101

Abstract

Dural arteriovenous fistulas (DAVFs) represent 10%-15% of all intracranial arteriovenous malformations.¹ DAVFs located in the posterior cranial fossa are rare and often present with intracranial hemorrhage and myelopathy.² Arterial supply could be provided by the meningeal branches of the vertebral artery and external and internal carotid arteries.³ A 68-year-old man presented with progressive lower-extremity weakness (Video 1). Magnetic resonance imaging revealed a patchy longitudinal cord signal abnormality extending from the cervicomedullary junction to C7. A tentorial DAVF supplied by the right posterior meningeal artery with drainage via dorsal and ventral perimedullary veins was identified on angiography. According to the Cognard classification, the patient's DAVF was determined to be high risk as a type V lesion with spinal venous drainage and progressive myelopathy.⁴ The fistula was embolized with 50% ethanol resulting in near-complete occlusion. However, follow-up angiography revealed a persistent arteriovenous shunt and slightly worsening symptoms for the patient. He underwent a sitting supracerebellar approach with a torcular craniotomy for successful clip ligation of the dural arteriovenous fistula. The patient was discharged with improvements in lower-extremity strength and no residual arteriovenous shunting in postoperative imaging.

Keywords: 3D video; Dural arteriovenous fistula; Myelopathy; Perimedullary veins; Posterior fossa; Posterior meningeal artery; Supracerebellar approach.

Publication types

Case Reports
Video-Audio Media

MeSH terms

Aged
Central Nervous System Vascular Malformations / complications
Central Nervous System Vascular Malformations / surgery*
Cranial Fossa, Posterior / pathology
Cranial Fossa, Posterior / surgery*
Humans
Male
Neurosurgical Procedures / education
Neurosurgical Procedures / methods*
Spinal Cord Diseases / complications
Surgical Instruments
Treatment Outcome