June 03, 2015
This is another case of a superior petrosal or a tentorial dural arteriovenous fistula. This is a 36 year-old male who presented with a sudden onset severe headache, nausea and dizziness, and on imaging and more specifically MRI, demonstrated a small hemorrhage within the middle cerebellar peduncle. There is an avascular abnormality in the same region and a 3D reconstruction of the CTA demonstrated some abnormal veins within the posterior fossa. Subsequently he underwent an angiogram, demonstrating the location of the dural intravenous fistula at the level of the petrous tentorial junction. You can see the feeding arteries from the ICA through the tentorium reaching the superior petrosal vein that is arterialized. Here's a later phase of the lateral ICA angiogram. He underwent a right sided retromastoid craniotomy, dura of the petrous bone, tentorium, the junction of the two. The arachnoid bands were widely dissected, so that multiple fistulas connections are not overlooked. Here's the seven and eighth cranial nerves, fifth cranial nerve, the fistula's connection. There's only one apparent. I attempted placing a straight clip, but one of the clip to be flushed with the tentorium, therefore I used a bin edit clip so I can see very well around the tips without any obstruction from their clip appliers. You can see the fistula is completely disconnected. Let's go ahead and do an intraoperative ICG angiogram to assure no other vessels are filling within this area. Here's the seventh and eighth cranial nerve. The fistula is completely disconnected. There's no other draining vein apparent in the area. This is the part of the fistula that is filling through the tentorium, but there's no outflow across the clip. Postoperative angiogram demonstrated complete exclusion of the fistula. And the three-months MRI demonstrated resolution of the hematoma and this patient made an excellent recovery, thank you.
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