- Let's review the principles of disconnection for superior petrosal or tentorial dural arteriovenous fistulas. This is a 39-year-old male, who presented with a spontaneous CP angle subarachnoid hemorrhage and facial numbness. CT scan demonstrated acute blood within the left side of the cyclopentane angle. An angiogram confirmed the presence of a superior petrosal sinus with draining veins within the posterior fossa. You can see the hypertrophied tentorial arteries leading to the fistula. 3D angiogram with bony reconstruction again demonstrates the location of the fistula at the level of the superior petrosal sinus or potentially two draining veins in this area that have to be found. Patient underwent retromastoid craniotomy. Here's the tentorium, dura of petrous bone, left sided approach. You can see two veins joining a single vein, both arterialized. I continue to look around the veins to assure that no other fistula's connection is overlooked. Here's the edge of the tentorium. Fourth nerve is protected. I place a straight clip across the main arterialized vein as close to the tentorium as possible. This method excludes both arterialized veins. Here's the trigeminal nerve for orientation. Subsequently both arterialized veins were coagulated and cut. Postoperative angiogram revealed complete disconnection of the fistula without any evidence of a V shunting. Here's the external injection, and three months MRI demonstrated no complicating features, and this patient's numbness significantly improved at the time of the followup. Thank you.
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