April 28, 2016
Here's another case example of a tentorial dural arteriovenous fistula, but this time the cortical draining vein is located within the super tentorial space, along the base of the poster temporal lobe. This is a 57 year old male who presented with a spontaneous posterior temporal intercranial hemorrhage. The location of the hemorrhage is evident here. There is a questionable vascular abnormality along the posterior temporal lobe, as evident on axial and coronal CT angiogram images. A cerebral arteriogram demonstrated the location of the fistula, fed primarily by a posterior branch of their middle meningeal artery leading to a cortical vein along the posterior temporal lobe, associated with a varix ultimately draining into the left transfer sinus. Patient underwent a left posterior temporal craniotomy just over the transfer sinus. A lumbar drain was placed at the beginning of the procedure for early brain relaxation and easy mobilization of the temporal lobe to expose the tentorium. You can see the incision based over and above the transfers sinus. Obviously the vein of Labbe is going to be implicated during the exposure and dural opening. Here is the transfer sinus, the dura is incised based over the transfer sinus. CSF is drained from the lumbar drain. Here is the vein of Labbe, that has to be mobilized for the frontal lobe to be elevated. And the vein of Labbe is here, go ahead and open some of the arachnoid bands in this area. But before the temporal lobe is further elevated, I have to untether the vein of Labbe entering the transfer sinus. This vein can be readily mobilized on untethered from the surrounding in casing arachnoid bands. Here's a normal vein along the tentorium here should be the area of the fistula, most likely leading to a draining vein traveling more anteriorly. So the fistula is essentially located within the tentorium and here's the origin of the arterialized draining vein moving anteriorly toward where the temporal lobe is. So here's the arterialized vein. This vein is further isolated. Here's a more demagnified view of our operative corridor for your orientation and reference. I tried a curve clip, but before I finalize the placement of a clip, I went ahead and removed the clip and performed an intraoperative fluorescene angiography. Again, demonstrating that this is the pathology in fact, you'll see there is early enhancement of the vein during the arterialized phase, showing that this is an arterialized vein. Here's the clip that was placed as close as possible to the level of the tentorium to disconnect the fistula. It's the final result. The draining vein, the vein of Labbe is intact. Postoperative angiogram demonstrated complete exclusion of the fistula without evidence of any complicating features on the CT scan and the patient made an excellent recovery. Thank you.
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