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Challenging Ethmoidal dAVF: Massive Bleeding

April 28, 2016


Let's talk about a very difficult case where I faced truly torrential and massive bleeding. This is in Ethmoidal or olfactory groove dura or to venous fistula. This is a 32 year-old male who presented to an outside hospital with massive intercranial hemorrhage in the left frontal area associated with a subdural hematoma. He presented in a very poor neurological condition and immediately underwent a left frontal craniotomy evacuation of the hematoma, and also an attempted disconnection of this dural arteriovenous fistula on the CT angiogram. The initial surgical team encountered massive amount of bleeding and multiple clips were deployed blindly and the patient ultimately made an excellent recovery and was referred to us for further intervention. I might as well at that after the initial operation, in the outside hospital, the patient underwent an attempted endovascular coiling of this fistula without significant success. This is the preoperative angiogram. Before I attempted this connection of this fistula through a left sided eyebrows, super orbital craniotomy. The initial incision was a Souter incision. A large frontal craniotomy, and I wanted to avoid the initial incision and therefore used an eyebrow incision. You can see the location of the fistula, a typical Ethmoidal fistula however, associated with a very large varix. The location of the clips from the initial operation is apparent. Obviously the clips are not disconnecting the fistula. Let's go ahead and review the intraoperative events. In this case, you can see the eyebrow incision on the left side. The eyebrows actually here retracted in ferry with the scalp with a fish hooks. You can see a left funnel, supraorbital craniotomy, midline is located here and the keyhole is located here. You can see a very small craniotomy. I did not feel additional exposure was necessary since the fistula was located very anteriorly along the olfactory groove and Ethmoidal region. The dura was opened in a curvilinear fashion. And ample amount of score was encountered from the previous operation. And I went ahead and did some arachnoidal dissection and was able to find the previous clips relatively readily. To better understand the vascular anatomy here, I have to cut some of the skull around the clips to be able to create more space for my clip to disconnect the fistula. I often use an 11 blade and cut this skull parallel to the clip lights in order to release the blades. Here's the large venous varix. There are arterialized venous varix in cutting across these clips, so I can create more space for disconnection of the fistula. Additional clips are uncovered. I believe there were at least three clips deployed blindly during the first operation. Here's the fistula. Let's go ahead and isolate the fistula. Relatively easy here you can see the frontal lobe, the clear optic area from the previous surgery. Obviously the feeding vessels connecting to the arterialized varix are within the dura of the olfactory groove and at this point my goal is essentially to disconnect the varix completely as close to the dura as possible. Here this clip that is essentially free floating, I'm not sure... Removal of the clip was absolutely necessary at this region. However, it appeared that the clip is not connected to any structure and therefore this clip was removed. Let's go ahead and focus our attention on the varix and its disconnection. This clip obviously is only partially adherent to the fistula and it's not encasing both walls of the fistula. Here's further dissection of the fistula more medially, towards the falx cerebri, so I can get a better look of the entire venous varix for final deployment of my clip. Here is the magnified view of the varix close to the midline. Here's the falx, connection of the varix to the dura and the falx. Place the predominant clip across the varix to assure disconnection of the large critical arterialized vein. After that maneuver was conducted, I felt good about the fact that the fistula has been primarily disconnected. However, during my inspection of the portion of the varix distal to the area, there was clip ligated. I encountered torn Shimano bleeding. It was really difficult to control the bleeding because of the large tear within the varix. Place the carotenoid patio over the area of the bleeding with gentle tamper note. So I can think more clearly about what maneuvers, I can utilize in controlling the bleeding. I placed another clip across the point of bleeding. However, this maneuver was not beneficial and did not assist with the bleeding. Now you can see the carotenoid stuck between the plates of the second clip. At this point, I was convinced that the initial clip did not close the fistula completely. And therefore there was some residual flow within the fistula, that led to this torrential bleeding. Here again you can see the immense amount of bleeding through this very small hole. A longer clip was employed. However, this maneuver did not appear to help in any way. You can see that by squeezing the fistula completely. I was able to control the bleeding. Another hint that most likely this clip is not completely disconnecting the fistula Bipolar coagulation was somewhat effective in closing the area of the bleeding. However, additional bleeding from the dura appeared to continue. I also believed at this point that there were other fistulas connections leading to the fistula from the dura that were not immediately handled with deployment of initial clip. Therefore the operator has always to look around and find other fistulas connections. Here you can see some gel foam powder soaked in thrombin was able to seal the bleeding through the dura, the fistula and the varix now appear collapsed. Here's another clip. I was happy with a final product. You can see the varix is now completely collapsed. I further inspected the area of the falx and the dura of the anterior cranial fossa immediately to make sure I have not overlooked any other arterialized veins. A postoperative angiogram revealed complete disconnection of the fistula. And the CT scan did not reveal any sign of complication and this patient made an excellent recovery. Thank you.

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