Tentorial dAVF: Multiple Fistulas
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Complex tentorial or superior patrol sole dural arteriovenous fistulas. Can not only have atypical presentation, but also carry multiple draining veins. All these draining veins have to be disconnected. For a complete exclusion of the arteriovenous shunting. This is a 44 year old female who presented with brainstem dysfunction. Unfortunately underwent a tracheostomy and was placed in a nursing home with our further workup. For the presumed diagnosis of brain stems stroke. Let's go ahead and review the initial imaging on this patient. You can see the evidence of the T2 signal change within the brain stem. However, the CT angiogram demonstrated a suspicious area of hyper vascularity or the left anterolateral aspect of the brain stem. Next angiography revealed a Conrad type for territorial dural arteriovenous fistula. Predominantly fed from the left poster division of the left middle meningeal artery. The meningeal images solely into a perimysium and cephalic draining vein communicating with their pretty pontine vein with subsequent outflow into the pre medullary venous plexus inferiorly. There was also partial occlusion of the transverses sigmoid sinuses, on this site. She subsequently underwent a left sided retromastoid craniotomy. Here's the petrous bone, the tentorium. The seventh and eighth cranial nerves. You can see some area of corkscrew vascularity. Over the posterior aspect of the seventh and eighth cranial nerves. Initially, there was nothing suspicious. I continued to persist and dissect. Around the fifth cranial nerve. You can see the rack on membranes were widely opened. Here's the trochlear nerve. Further inspection along the anterior aspect of the fifth credit nerve revealed some suspicious vessels. Further dissection in this area, obviously as indicated. Here's the inferior aspect of the nerve. I'm going to focus my attention along the superior aspect of the nerve. Whereas suspicious vein is also apparent more eventually. Here you could see that suspicious vein joining the area where the superior petrosal sinus will be entering the tentorial petrous junction. Here's that hypervascular area. Or arterialized vein, which is the area of the fistula. However, identification of the one fistulas connection should not prevent a surgeon from looking further to find potentially another fistulas connection as well. I attempted to play say straight clip across this fistula. However, the reach was far. The clip had to be repositioned to be completely across if fistulas vein. Here's repositioning of the vein across the arterialized vein were slightly angled. Clip applier was used. After this arterialized vein was disconnected. I inspected further here is the premise and cephalic vein that appears to be more blue now. And collapse here was another fistulas vein. That was also apparent let's go ahead and review that sicken arterialized vein. Which was actually posterior to the entry zone of the trigeminal nerve. This vein was also occluded. Further inspection of you'll know, other arterialized veins. Let's go ahead and do an intraoperative ICG angiogram. Can see the initial vein is completely occluded upon further inspection. You can see that all the veins are adequately disconnected. Especially the veins that were arterialized. And postoperative angiogram also confirms exclusion of the tentorial dural arteriovenous fistula. More specifically, this patient made an incredible recovery. Her brainstem edema subsided significantly. And she also regained most of her function. Thank you.
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