SURGICAL VIDEO Microsurgical Management of Galenic Dural Arteriovenous Fistula: 3-Dimensional Operative Video Arnau Benet, MD,* Michael T. Lawton, MD*‡ *Department of Neurosurgery, University of California, San Francisco, San Francisco, California; ‡Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California Watch now at http://bit.ly/1MKxdL7 This video demonstrates the microsurgical management of a galenic dural arteriovenous fistula (DAVF). This 37-year-old woman presented with severe headaches, and evaluation with magnetic The 3-D video can be viewed at http://bit.ly/1MKxdL7 resonance imaging demonstrated an incidental vascular malforma- tion in the quadrigeminal cistern. Catheter angiography revealed Disclosure a galenic DAVF supplied bilaterally by tentorial and meningeal The authors have no personal, financial, or institutional interest in any of the drugs, arteries, as well as branches of posterior cerebral and superior materials, or devices described in this article. cerebellar arteries (arteries of Davidoff and Schechter). The deep venous system no longer drained through the vein of Galen or straight sinus and used anterior collaterals instead. The DAVF was COMMENT aggressively embolized transarterially, but numerous feeders pre- vented curative obliteration, and tortuous draining veins prevented alenic dural arteriovenous fistulas are a rare and complex pathology transvenous access. A torcular craniotomy and posterior interhemi- G with a devastating natural history. Dr Lawton’s experience with spheric approach were performed to occlude the fistula. The patient surgical management of these lesions is highlighted by impressive ra- diographic results and clinical outcomes. This operative video demon- was positioned laterally to allow gravity to retract the right occipital strating mobilization of the falcotentorial junction and isolation of the lobe. Transecting the falx and tentorium bilaterally skeletonized the venous drainage of this challenging lesion is a meaningful adjunct to his straight sinus, which visualized the posterior cerebral and superior series of tentorial dural arteriovenous fistulas and is of great educational cerebellar artery feeders and the dilated draining galenic veins. value to vascular neurosurgery. Right-angle fenestrated clips were applied in tandem to close the vein of Galen, thereby occluding the fistula on the venous side. Indocyanine green angiography was used to identify and then Daniel M. Heiferman occlude additional venous outflow. Postoperative angiogram con- Christopher M. Loftus firmed occlusion of the DAVF, and the patient recovered with no Maywood, Illinois neurological deficits at 4 months. This case illustrates galenic DAVFs and the posterior interhemispheric approach to this region. The benefits of gravity retraction, falcotentorial transection, and 1. Lawton MT, Sanchez-Mejia RO, Pham D, et al. Tentorial dural arteriovenous indocyanine green angiography are demonstrated. After the venous fistulas: operative strategies and microsurgical results for six types. Neurosurgery. outflow is interrupted, the fistulous pathology can remain in situ. 2008;62(3 suppl 1):110-124. OPERATIVE NEUROSURGERY VOLUME 12 | NUMBER 4 | DECEMBER 2016 | 391 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
Operative Neurosurgery – Oxford University Press
Published: Dec 1, 2016
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