Tentorial dAVF: Basic Techniques for Disconnection

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This video reviews the tenets for disconnection of tentorial or superior petrosal dural arteriovenous fistulas. This is a 61 year old female who presented with a spontaneous, right-sided cerebellar intraparenchymal hemorrhage. You can see the location of the hemorrhage. The angiogram demonstrated a tentorial or superior petrosal dural arteriovenous fistula associated with numerous venous varices within the posterior fossa. The patient subsequently underwent a right-sided retromastoid craniotomy. Here is the petrous bone tentorium petrotentorial junction. The arachnoid bands are thoroughly disconnected so that the arterialized superior petrosal vein can be identified. An important maneuver is to circumventially dissect the arterialized vein in order to exclude the presence of any other secondary arterialized veins. One has to avoid overlooking any other arterialized veins that may lead to sub-optimal disconnection of the fistula. You can see while looking around the arterialized vein I can not find any other fistulas connection. Therefore, a definitive permanent clip was placed across a single arterialized vein. You can see some expansion of the portion of the vein closer to the tentorium. This finding is not unusual. Let's go ahead and do an ICG. You can see the fistulas connection is no longer filling toward the posterior fossa. There's no other arterialized vein visualized in the vicinity of the initial arterialized vein. I'm satisfied with the extent of disconnection. Postoperative angiogram also confirms complete exclusion of the fistula without any evidence of filling of those arterialized varices within the posterior fossa. Thank you.

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