Let's review a case of a simple middle fossa dural arteriovenous fistula. This is a 62-year old male presented with an acute onset subarachnoid hemorrhage. You can see the pattern of the hemorrhage here. Angiogram demonstrated a small dural arteriovenous fistula being fed primarily by a basal tentorial branch of the middle meningeal artery. The draining vein join the sigmoid sinus or the transfer sigmoid junction. Patient underwent a right-sided temporal or sub-temporal craniotomy, a lumbar drain was installed at the beginning of the procedure. Temporalis muscle, a linear incision was utilized. The root of the zygoma is located here. Some of the mastoid air cells that were waxed, again, the flow of the middle fossa. Dura was opened in a curvilinear fashion. CSF was drained through the lumbar drain and the temple was gently elevated. I was looking for a large arterialized vein just over the dura. Here's a normal vein. That would be a good reference point to find our arterialized vein here. You can see the arterialized vein, which is somewhat brighter than the dark vein here. That distinction is more apparent now. You can see the arterialized vein and a normal vein, and another normal vein. So essentially, the arterialized vein was sandwiched between two normal veins. It was difficult to just disconnect this arterialized vein between these veins, therefore one of the veins was taken or sacrificed. Here's another view, and a comparison of the arterialized vein to the normal veins at the dura of the middle fossa floor. The lateral normal vein was sacrificed, and next, the arterialized vein was coagulated. Here, you can see the coagulation of the arterialized vein. Further dissection assures that this arterialized vein is completely non-functional. No other abnormality was found more immediately. Again, the other vein also was disconnected to exclude any chance of a vascular abnormality along the dura of the middle fossa. Looking further interiorly, a suspicious vein was encountered and was also disconnected. These veins were quite related along their length. Here's the final result. The postoperative CT scan did not reveal any evidence of complication and the post operative angiogram confirmed complete disconnection of the fistula. Thank you.
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