TechniqueSelective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report
Introduction
Dural arteriovenous fistulas account for 10% to 15% of all intracranial arteriovenous lesions [4]. Their venous pattern of drainage determines the risk of neurologic complication. This risk increases in the presence of venous reflux into a main sinus and leptomeningeal vessels [2], [4], [5].
The goal of the treatment is the complete exclusion of the lesion. Surgery can be associated with a high complication rate. Nowadays, transvenous embolization has proven to be efficient and the first treatment option in some location [6], [10]. Nevertheless, this treatment is sometimes not applicable because the venous access can be prevented by the sinus thrombosis often associated or by previous treatments. In such cases, surgical exposure of the sinus is an elegant option to permit further transvenous DAVF occlusion [4]. In their experience, Houdart et al [4] advised to perform a large craniectomy owing to the failure of the subsequent endovascular treatment after small ones.
To avoid the disadvantages and complications associated with large craniectomies in cases of DAVF, we have performed an SIGC. We detail our surgical technique and discuss its advantages and pitfalls.
Section snippets
Case report
This 58-year-old woman has a 2-year history of left pulsatile tinnitus. She was admitted after an abrupt neurologic deterioration. Neurologic examination revealed a deep coma. Computed tomography scan showed a right-sided cerebellar hematoma responsible for hydrocephalus. The patient was brought in the operating room for cerebrospinal fluid tap and hematoma drainage. Surgery was associated with profuse and unusual bleedings all over the procedure. The patient's neurologic condition improved
Discussion
The transcranial approach was first described by Mickle and Quisling [7] in 1986 for the transtorcular embolization of vein of Galien aneurysms. The transcranial access has then been reported to catheterize the transverse sinus and the superior sagittal sinus [1], [3], [4], [8]. Based on the largest published experience, Houdart et al [4] advocated performing large craniectomies. In fact, 7 of their 10 patients needed to be reoperated on to enlarge a craniectomy because it was either too small
Conclusion
Selective image-guided craniectomy allows the direct percutaneous transvenous embolization of DAVF in the same anesthetic session. The bone beside the sinus borders has to be drilled to allow an adequate sharp puncture angle but must be left in place to prevent traumatic parenchymal puncture. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter, and the possibility of direct compression.
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