Microsurgical Management of a Marginal Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Visish M Srinivasan ◽  
Joshua S Catapano ◽  
Fabio A Frisoli ◽  
Michael A Mooney ◽  
Michael T Lawton
Keyword(s):  
Chronic Neck Pain ◽  
Foramen Magnum ◽  
Endovascular Embolization ◽  
Venous Hypertension ◽  
Indocyanine Green Videoangiography ◽  
Marginal Sinus ◽  
Arteriovenous Fistulas ◽  
Full Resolution ◽  
Complete Obliteration ◽  
Life Threatening

Abstract Dural arteriovenous fistulas (DAVFs) are benign but may present with life-threatening hemorrhage or symptoms of venous hypertension (eg, progressive myelopathy).1-3 DAVFs follow well-described anatomic patterns.4 The marginal sinus is located between the layers of the dura, circumferentially around the foramen magnum. It communicates with the basal venous plexus of the clivus anteriorly and the occipital sinus posteriorly.5,6 Arterial supply to the dura in this region that fistulizes into the sinus arises from meningeal branches from the V3 or V4 segments.  A man in his early 70s presented with chronic neck pain and new onset of left arm and face paresthesias. He had brisk patellar reflexes bilaterally and a marginal sinus DAVF, with numerous dilated veins around the cisterna magna, causing dorsal cervicomedullary compression. Angiography confirmed the diagnosis of DAVF rather than arteriovenous malformation. Endovascular embolization was considered, but surgery was preferable because of poor transarterial access.  The patient underwent left far lateral craniotomy and C1 laminectomy with exposure of the condylar fossa. The dura was carefully elevated laterally, revealing a network of dilated tortuous veins, with multiple points of fistulous connection within the dura emanating in a large venous varix. Indocyanine green videoangiography showed the aberrant flow dynamics. The fistulous point was occluded with aneurysm clips on the venous side, then cauterized and interrupted. The patient was discharged within 3 d of surgery and had full resolution of symptoms at 6 wk. Angiography confirmed complete obliteration of the DAVF. The patient provided written informed consent for treatment. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Advances in Surgical Approaches to Dural Fistulas

Neurosurgery ◽  
2014 ◽  
Vol 74 (suppl_1) ◽  
pp. S32-S41 ◽  
Author(s):  
Patrick P. Youssef ◽  
Albert Jess Schuette ◽  
C. Michael Cawley ◽  
Daniel L. Barrow
Keyword(s):  
Treatment Options ◽  
Venous Drainage ◽  
Venous Hypertension ◽  
Surgical Approaches ◽  
Dural Sinus ◽  
Intraoperative Angiography ◽  
Indocyanine Green Videoangiography ◽  
Arteriovenous Fistulas ◽  
The Past ◽  
Dural Arteriovenous Fistulas

Abstract Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

scholarly journals The role of microscope-integrated near-infrared indocyanine green videoangiography in the surgical treatment of intracranial dural arteriovenous fistulas

2015 ◽  
Vol 122 (4) ◽  
pp. 876-882 ◽  
Author(s):  
Harjot Thind ◽  
Douglas A. Hardesty ◽  
Joseph M. Zabramski ◽  
Robert F. Spetzler ◽  
Peter Nakaji
Keyword(s):  
Indocyanine Green ◽  
Near Infrared ◽  
False Negative ◽  
False Negative Rate ◽  
Indocyanine Green Videoangiography ◽  
Surgical Ligation ◽  
Arteriovenous Fistulas ◽  
Negative Rate ◽  
Independent Form ◽  
Complete Obliteration

OBJECT The successful treatment of an intracranial dural arteriovenous fistula (dAVF) requires complete obliteration of blood flow through the fistulous point. Surgical ligation is often used along with endovascular techniques. Digital subtraction angiography (DSA) can be used to confirm fistula obliteration; however, this technique can be cumbersome intraoperatively and difficult to correlate anatomically with the surgical field. Near-infrared indocyanine green (ICG) videoangiography has been described as a complementary tool for this purpose. METHODS The authors examined intracranial dAVF cases in which microscope-integrated intraoperative ICG videoangiography was used to identify and/or confirm obliteration of the dAVF during surgery. Retrospective evaluation of all intracranial dAVF cases treated with surgical ligation over a 10-year period at the Barrow Neurological Institute (n = 47) revealed 28 cases in which ICG videoangiography was used. The results were compared with findings on preoperative and intraoperative or postoperative DSA. RESULTS ICG videoangiography successfully confirmed the fistulous point intraoperatively in 96% (22/23) of the cases. It also revealed complete obliteration of fistulas, comparable to intraoperative or postoperative DSA, in 91% (21/23) of the cases. The false-negative rate of ICG was 8.7% (2/23), which is similar to the false-negative rate of intraoperative DSA alone (10.5% [2/19]). CONCLUSIONS Microscope-based ICG videoangiography provides real-time information about the intraoperative anatomy of dAVFs. In addition, it can confirm complete obliteration of a fistula. This technique may be useful during dAVF surgery as an independent form of angiography or as an adjunct to intraoperative or postoperative DSA.

scholarly journals Bilateral Cervical Spinal Dural Arteriovenous Fistulas with Intracranial Venous Drainage Mimicking a Foramen Magnum Dural Arteriovenous Fistula

2013 ◽  
Vol 19 (4) ◽  
pp. 483-488 ◽  
Author(s):  
Steven W. Hetts ◽  
Joey D. English ◽  
Shirley I. Stiver ◽  
Vineeta Singh ◽  
Erin J. Yee ◽  
...  
Keyword(s):  
Arteriovenous Fistula ◽  
Dural Arteriovenous Fistula ◽  
Venous Drainage ◽  
Foramen Magnum ◽  
Venous Hypertension ◽  
Complex Case ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Diagnostic Angiography ◽  
Spinal Dural Arteriovenous Fistulas

We describe a unique case of bilateral cervical spinal dural arteriovenous fistulas mimicking an intracranial dural arteriovenous fistula near the foramen magnum. We review its detection via MRI and digital subtraction angiography and subsequent management through surgical intervention. Pitfalls in diagnostic angiography are discussed with reference to accurate location of the fistula site. The venous anastomotic connections of the posterior midline spinal vein to the medial posterior medullary vein, posterior fossa bridging veins, and dural venous sinuses of the skull base are discussed with reference to problem-solving in this complex case. The mechanism of myelopathy through venous hypertension produced by spinal dural fistulas is also emphasized.

scholarly journals Overview of the current role of endovascular and surgical treatment in spinal dural arteriovenous fistulas

2009 ◽  
Vol 26 (1) ◽  
pp. E8 ◽  
Author(s):  
Amir R. Dehdashti ◽  
Leodante B. Da Costa ◽  
Karel G. terBrugge ◽  
Robert A. Willinsky ◽  
Michael Tymianski ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Vascular Malformations ◽  
Endovascular Embolization ◽  
Vascular Lesions ◽  
Current Role ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Complete Obliteration ◽  
Spinal Dural Arteriovenous Fistulas

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.

The role of surgery for high-grade intracranial dural arteriovenous fistulas: importance of obliteration of venous outflow

2009 ◽  
Vol 110 (5) ◽  
pp. 913-920 ◽  
Author(s):  
James K. Liu ◽  
Aclan Dogan ◽  
Dilantha B. Ellegala ◽  
Jonathan Carlson ◽  
Gary M. Nesbit ◽  
...  
Keyword(s):  
Surgical Intervention ◽  
Transarterial Embolization ◽  
Endovascular Embolization ◽  
Venous Hypertension ◽  
Neurological Deficits ◽  
Definitive Treatment ◽  
Radical Excision ◽  
Venous Outflow ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas

Object Surgical intervention may be required if endovascular embolization is insufficient to completely obliterate intracranial dural arteriovenous fistulas (DAVFs). The authors report their 14-year experience with 23 patients harboring diverse intracranial DAVFs that required surgical intervention. Methods Between 1993 and 2007, 23 patients underwent surgery for intracranial DAVFs. The following types of DAVFs were treated: superior petrosal sinus (in 10 patients); parietooccipital (in 3); confluence of sinuses and ethmoidal (in 2 each); and tentorial, falcine, occipital, transverse-sigmoid, superior sagittal, and cavernous sinuses (in 1 patient each). In all cases, the authors' goal was to obliterate the DAVF venous outflow by direct surgical interruption of the leptomeningeal venous drainage. Transarterial embolization was used primarily as an adjunct to decrease flow to the DAVF prior to definitive treatment. Results Complete angiographic obliteration of the DAVF was achieved in all cases. There were no complications of venous hypertension, venous infarction, or perioperative death. There were no recurrences and no further clinical events (new hemorrhages or focal neurological deficits) after a mean follow-up of 45 months. Conclusions The authors' experience emphasizes the importance of occluding venous outflow to obliterate intracranial DAVFs. Those that drain purely through leptomeningeal veins can be safely obliterated by surgically clipping the arterialized draining vein as it exits the dura. Radical excision of the fistula is not necessary.

Emergent Hybrid Treatment of a Ruptured Scalp Arteriovenous Fistula with Eyelid involvement: Technical Note

2021 ◽  
Author(s):  
Juan Felipe Abaunza-Camacho ◽  
David Vergara-Garcia ◽  
Francisco Perez ◽  
Camilo Benavides ◽  
Alberto Caballero ◽  
...  
Keyword(s):  
Hypovolemic Shock ◽  
Endovascular Embolization ◽  
Technical Note ◽  
Medical Emergency ◽  
Severe Bleeding ◽  
Acute Anemia ◽  
Arteriovenous Fistulas ◽  
Life Threatening ◽  
Type C ◽  
Open Surgical Approach

Abstract Background Scalp arteriovenous fistulas (AVFs) are a rare vascular disease usually presenting as a progressively increasing pulsating mass in the scalp. These lesions can be associated with mild to severe complications, including congestive heart failure. If ruptures, this pathology constitutes a life-threatening medical emergency because of its potential to cause severe bleeding and acute anemia. Methods We describe the case of a young woman with a ruptured Yokouchi type C scalp AVF with eyelid involvement. Results The patient presented with hypovolemic shock and acute anemia due to severe bleeding from the lesion. Emergent treatment through a combined endovascular and open surgical approach was required to stop bleeding and stabilize the patient. Conclusions Emergent and effective treatment is required to stop bleeding when a scalp AVF ruptures. A combination of endovascular embolization and microsurgical excision of the shunt is a treatment option.

scholarly journals Dural arteriovenous fistula-induced thalamic dementia: report of 4 cases

2016 ◽  
Vol 124 (6) ◽  
pp. 1752-1765 ◽  
Author(s):  
Terrence F. Holekamp ◽  
Matthew E. Mollman ◽  
Rory K. J. Murphy ◽  
Grant R. Kolar ◽  
Neha M. Kramer ◽  
...  
Keyword(s):  
Venous Drainage ◽  
Diagnostic Procedures ◽  
Endovascular Embolization ◽  
Venous Hypertension ◽  
Neurological Deficits ◽  
Progressive Dementia ◽  
Arteriovenous Fistulas ◽  
Presenting Symptoms ◽  
Dementia Syndrome ◽  
Increased Risk

Nonhemorrhagic neurological deficits are underrecognized symptoms of intracranial dural arteriovenous fistulas (dAVFs) having cortical venous drainage. These symptoms are the consequence of cortical venous hypertension and portend a clinical course with increased risk of neurological morbidity and mortality. One rarely documented and easily misinterpreted type of nonhemorrhagic neurological deficit is progressive dementia, which can result from venous hypertension in the cortex or in bilateral thalami. The latter, which is due to dAVF drainage into the deep venous system, is the less common of these 2 dementia syndromes. Herein, the authors report 4 cases of dAVF with venous drainage into the vein of Galen causing bithalamic edema and rapidly progressive dementia. Two patients were treated successfully with endovascular embolization, and the other 2 patients were treated successfully with endovascular embolization followed by surgery. The radiographic abnormalities and presenting symptoms rapidly resolved after dAVF obliteration in all 4 cases. Detailed descriptions of these 4 cases are presented along with a critical review of 15 previously reported cases. In our analysis of these 19 published cases, the following were emphasized: 1) the clinical and radiographic differences between dAVF-induced thalamic versus cortical dementia syndromes; 2) the differential diagnosis and necessary radiographic workup for patients presenting with a rapidly progressive thalamic dementia syndrome; 3) the frequency at which delays in diagnosis occurred and potentially dangerous and avoidable diagnostic procedures were used; and 4) the rapidity and completeness of symptom resolution following dAVF treatment.

scholarly journals Uterine Arteriovenous Fistula with Concomitant Pelvic Varicocele: Endovascular Embolization with Onyx-18®

2017 ◽  
Vol 2017 ◽  
pp. 1-5
Author(s):  
Francesco Giurazza ◽  
Fabio Corvino ◽  
Andrea Paladini ◽  
Antonio Borzelli ◽  
Domenico Scognamiglio ◽  
...  
Keyword(s):  
Arteriovenous Fistula ◽  
Clinical Success ◽  
Young Patients ◽  
Endovascular Embolization ◽  
Childbearing Age ◽  
Arteriovenous Fistulas ◽  
Uterine Arteries ◽  
Life Threatening ◽  
History Of ◽  
Endovascular Approach

Uterine arteriovenous fistulas are rare and acquired causes of life-threatening vaginal bleeding. They usually present with intermittent menometrorrhagia in young patients in childbearing age with history of gynecological procedures on uterus. Traditional management is hysterectomy; endovascular embolization represents nowadays an alternative strategy for patients wishing to preserve fertility. Here, the endovascular approach to a 29-year-old woman affected by severe menometrorrhagia caused by a uterine arteriovenous fistula with a concomitant pelvic varicocele is reported; a bilateral uterine arteries embolization with Onyx-18 (ev3, Irvine, CA, USA) has successfully resolved the fistula with clinical success.

Spinal extradural arteriovenous fistulas

2013 ◽  
Vol 19 (5) ◽  
pp. 582-590 ◽  
Author(s):  
Wendy Huang ◽  
Bradley A. Gross ◽  
Rose Du
Keyword(s):  
Treatment Strategies ◽  
Venous Drainage ◽  
Neurofibromatosis Type ◽  
Venous Hypertension ◽  
High Rate ◽  
Treatment Modalities ◽  
Arteriovenous Fistulas ◽  
Pubmed Database ◽  
Complete Obliteration

Object Our understanding of spinal extradural arteriovenous fistulas (eAVFs) is relatively limited. In this study the authors aimed to provide the demographics, natural history, and treatment results of these rare lesions. Methods The authors performed a pooled analysis of data in the PubMed database through December 2012. Individualized patient data were extracted to elucidate demographic, clinical, and angioarchitectural features of spinal eAVFs as well as outcomes following different treatment strategies. Results Information on 101 patients was extracted from 63 eligible studies. The mean patient age was 45.9 years, and there was no significant overall sex predilection. Only 3% of the lesions were incidental, whereas 10% occurred in patients who had presented with hemorrhage. None of the 64 patients with at least 1 month of untreated follow-up sustained a hemorrhage over a total of 83.8 patient-years. Patients with lumbosacral eAVFs were significantly older (mean age 58.7 years, p < 0.0001), were significantly more often male (70% male, p = 0.02), had significantly worse presenting Aminoff-Logue motor and bladder scores (p = 0.0008 and < 0.0001, respectively), and had the greatest prevalence of lesions with intradural venous drainage (62% of cases, p < 0.0001). Neurofibromatosis Type 1 (30% of cases, p < 0.0001) and subarachnoid hemorrhage (9% of cases, p = 0.06) were associated with and exclusively found in patients with cervical eAVFs. The overall complete obliteration rate was 91%. After a mean follow-up of 1.7 years, the clinical condition was improved in 89% of patients, the same in 9%, and worse in 2%. Obliteration rates and outcome at follow-up did not significantly differ between surgical and endovascular treatment modalities. Conclusions Spinal eAVFs are rare lesions with a low risk of hemorrhage; they cause neurological morbidity as a result of mass effect and/or venous hypertension. Their treatment is associated with a high rate of complete obliteration and improvement in preoperative symptoms.

Dural arteriovenous fistulas draining into the petrosal vein or bridging vein of the medulla: possible homologs of spinal dural arteriovenous fistulas

2009 ◽  
Vol 111 (5) ◽  
pp. 889-899 ◽  
Author(s):  
Yutaka Mitsuhashi ◽  
Thaweesak Aurboonyawat ◽  
Vitor Mendes Pereira ◽  
Sasikhan Geibprasert ◽  
Frédérique Toulgoat ◽  
...  
Keyword(s):  
Endovascular Embolization ◽  
Venous Hypertension ◽  
Venous Reflux ◽  
Male Predominance ◽  
Arteriovenous Fistulas ◽  
Petrosal Vein ◽  
Therapeutic Choice ◽  
Dural Arteriovenous Fistulas ◽  
Bridging Vein ◽  
Spinal Dural Arteriovenous Fistulas

Object Dural arteriovenous fistulas (DAVFs) with leptomeningeal venous reflux generally pose a high risk of aggressive manifestations including hemorrhage. Among DAVFs, there is a peculiar type that demonstrates direct drainage into the bridging vein rather than the dural venous sinus. The purpose of this study was to investigate the characteristics of DAVFs that drain directly into the petrosal vein or the bridging vein of the medulla oblongata. Methods Eleven consecutive cases of DAVFs that drained directly into the petrosal vein and 6 that drained directly into the bridging vein of the medulla were retrospectively reviewed. These cases were evaluated and/or treated at Hospital de Bicêtre in Paris, France, over a 27-year period. A review of previously reported cases was also performed. Results Both of these “extrasinusal”-type DAVFs demonstrated very similar characteristics. There was a significant male predominance (p < 0.001) for this lesion, and a significantly higher incidence of aggressive neurological manifestations including hemorrhage or venous hypertension than in DAVFs of the transverse-sigmoid or cavernous sinus (p < 0.001). This finding was considered to be attributable to leptomeningeal venous reflux. Regarding treatment, endovascular embolization (either transarterial or transvenous) is frequently difficult, and surgery may be an effective therapeutic choice in many instances. Conclusions Embryologically, both the petrosal vein and the bridging vein of the medulla are cranial homologs of the spinal cord emissary bridging veins that drain the pial venous network. The authors believe that DAVFs in these locations may be included in a single category with spinal DAVFs because of their similar clinical characteristics.

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