This video has a very provocative theme, and that is, do not believe what you see. It demonstrates the pitfalls in diagnosis of hemorrhagic, cervical spinal dural arteriovenous fistulas. This is a 75 year old male who presented with sudden onset neck pain, headache, and nausea. He was brought to the emergency room in a delayed fashion two days after his ictus. He suffered from renal insufficiency. The initial CT scan demonstrated hemorrhagic contents within the fourth ventricle. Also these contents layered in the lateral ventricles. MRA showed an anterior communicating artery aneurysm. One may think that the cause of the hemorrhage is the aneurysm, specially since the patient presented into a delayed fashion. However, the presence of the blood in the fourth ventricle in this patient was suspicious. Also the patient complained of neck pain, therefore, I obtained a CT angiogram of the neck just to rule out a pathology there. And as you can see, there is a suspicion of a dural arteriovenous fistula at the level of the mid cervical spine. MRI evaluation was relatively non revealing at the level of the cervical spine, besides evidence of moderate spondylosis. The patient's subsequently underwent an angiogram. You can see the arteriovenous fistula, at the level of mid cervical spine. I believe the cause of hemorrhage is the fistula, therefore the patient underwent a cervical laminectomy for disconnection of the fistula. Upon opening the dura, there was dense amount of hemorrhagic byproducts. Again, confirming my suspicion that the cause of hemorrhage was the fistula. The fistulas connection typically is located along the posteriolateral aspect of the nerve root. Here's the arterialized vein, obviously joining the vein over the posterior surface of the spinal cord. A temporary clip was placed on the fistula. Here is the nerve root. And I continued to inspect the area to assure that no other fistulas connection is overlooked. As you can see here, there is another fistulas connection that has to be disconnected. One more time. Thorough investigation of the area is important to avoid missing any of the fistulas connections, since they can be multiple ones. After the temporary clip was placed, this fistulas connection was coagulated on both sides of the blades and sacrificed. Removal of the clip after coagulation and transection of this fistulas connection would allow a more thorough inspection along the dorsal nerve root. When truly there is no other obvious fistulas connection that has to be taken care of. You can see anterior to the nerve root, everything appears intact without any vascular pathology. I also inspected the veins along the posterior surface of the spinal cord. You can see the veins appear dark blue and relatively collapsed. So I felt the pathology has been addressed. The postoperative angiogram confirmed disconnection of the fistula without any evidence of even minor arteriovenous shunting. And this patient recovered from his surgery uneventfully. Thank you.
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