Let's review the intra-operative events for disconnection of a supratentorial, parasagittal dural arteriovenous fistula. This is a 72 year old male who presented with sudden onset left upper extremity weakness that resolved within a month. The patient presented to the emergency room. You can see evidence of acute hemorrhage within the medial part of the right parietal lobe, an angiogram involving the internal carotid artery territories revealed no abnormality. However, study of the external carotid artery circulation demonstrated a large dural arteriovenous fistula within the parasagittal region, primarily fed by bilateral middle meningeal arteries. The parasagittal fistulas can be at times quite complex fed by multiple branches of the middle meningeal arteries and residual fistula, after adequate Intra-operative clip ligation may not be an uncommon finding. Patient underwent a right-sided parasagittal craniotomy. You can see the quarter call parasagittal. There are seas here's the superior sagittal sinus. The fistula should be located in entering the dural at this location. Therefore dissection in this area was continued. ICG demonstrated, most likely the location of the fistula, around the area of the superior sagittal sinus. The flow within the various seizes also apparent. Next all will continue dissection in the parasaggital space to find the arterialized vein. Here are some of the veins that appear to be maybe slightly high arterialized. However their, identity is further confirmed with circumferential dissection of the vessels in this area. Further dissection, inferior to this pre-sagittal sinus revealed the fistulas connection joining the dural. Here is further circumferential isolation of the fistula toward the dura. You can see the thick wall arterialized fistulas connection. No other obvious fistulas connection is apparent This appears to be a relatively normal non arterialized vein. A permanent straight clip was praised across their arterialized vein Repeat the intra-operative. ICG angiogram would be helpful. You can see the clip is across the entire caliber off the vessel. It's bean appears dark blue. Let's go ahead and see the ICG findings. There is no evidence of another fistula. The flow within the various seas is no longer apparent. I'm relatively satisfied with the results of this, this connection. In this case as a post-operative angiogram, or even an intraoperative angiogram is quite important. Intra-operative angiography in this case, demonstrated complete exclusion of the fistula However, a high resolution postoperative angiogram demonstrated slight feeling and small residual fistulas connection. This patient subsequently underwent intra-arterial or endovascular embolization of this small residual fistula and the final result demonstrates no more heavy shunting. Thank you.
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