SURGICAL VIDEO Intracranial Dural Arteriovenous Fistula: 2-Dimensional Operative Video Helbert de Oliveira Manduca Palmiero, MD ∗ , Bruno Augusto Lourenço Costa, MD ∗ , Ricardo Lourenço Caramanti, MD ∗ , Marcos Devanir Silva da Costa, MD ‡ , Feres Eduardo Aparecido Chaddad-Neto, MD, PhD § ∗ Neurosurgeon, Fellowship in Vascular Neurosurgery, Department of Neurosurgery, Federal University of São Paulo, Unifesp, São Paulo, Brazil; ‡ Neurosurgeon, Department of Neurosurgery, Federal University of São Paulo, Unifesp, São Paulo, Brazil; § Department of Neurosurgery, Head of Vascular Neurosurgery Division, Federal University of São Paulo, Unifesp, São Paulo, Brazil A dural arteriovenous fistula (DAVF) is an uncommon vascular malformation that has a direct dural arterial supply to a venous sinus. 1, 2 A DAVF is acquired after trauma and thrombosis, 2 and is most common in elderly women. 3 The principal location of a DAVF is the cavernous sinus, followed by the transverse sinus, and presents with pulsatile tinnitus. 3 , 4 Endovascular embolization has become first-line treatment, although microsurgery is most likely to result in successful oblit- eration. 2 However, in selected cases in which embolization is difficult because of proximity to neural structures, such as the cranial nerves, and because of the risk of compromising the pial supply, open surgery may be necessary. A 70-yr-old woman presented with headache and pulsatile tinnitus without neurological deficits. The patient signed the Institutional Consent Form, which allows the use of his/her images and videos for any type of medical publications in confer- ences and/or scientific articles. Magnetic resonance imaging demonstrated anomalous contrast uptake between the transverse sinus and right cerebellar hemisphere suggesting a DAVF. The DAVF is better identified on arteriography. The angiogram identified a direct arteriovenous shunt between a meningeal branch of the left vertebral artery, with retrograde drainage through the right inferior vermian vein to the straight sinus in the torcular area, ie, a Borden/Cognard type 3 fistula. 5 Onyx R  , a liquid embolic agent (Micro Therapeutics Inc, Irvine, California), was injected into the meningeal artery but not across the fistula into the draining vein, resulting in a residual fistula. Therefore, surgical treatment was indicated after unsuccessful embolization. Suboccipital craniotomy was performed, and the fistula site was identified with indocyanine. After clipping the fistula near the transverse sinus, we observed a decrease in flow. Accordingly, we performed the coagulation and incised the fistula near the dural sinus. The patient was discharged with remission of symptoms. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/ opx273 Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Ghobrial GM, Marchan E, Nair AK, et al. Dural arteriovenous fistulas: a review of the literature and a presentation of a single institution’s experience. World Neurosurg. 2013;80(1-2):94-102. 2. Oh JT, Chung SY, Lanzino G, et al. Intracranial dural arteriovenous fistulas: clinical characteristics and management based on location and hemodynamics. J Cerebrovasc Endovasc Neurosurg. 2012;14(3):192-202. 3. Kim MS, Han DH, Kwon OK, Oh CW, Han MH. Clinical characteristics of dural arteriovenous fistula. J Clin Neurosci. 2002;9(2):147-155. 4. Signorelli F, Della Pepa GM, Sabatino G, et al. Diagnosis and management of dural arteriovenous fistulas: a 10 years single-center experience. Clin Neurol Neurosurg. 2015;128(1):123-129. 5. Cognard C, Gobin YP, Pierot L. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 1995;194(3):671-680. COMMENTS T The authors describe the surgical disconnection of a high grade peritorcular DAVF draining via an inferior cerebellar vein after a failed attempt at transarterial embolization. Detailed analysis of the preoperative angiogram in conjunction with direct visualization of the draining vein and intraoperative indocyanine green angiogram helps avoid the pitfalls of nonfistulous venous occlusion and incomplete disconnection. A delayed follow-up angiogram after at least 6 months is useful to confirm a robust occlusion of the fistula. Michael C. Hurley Chicago, Illinois D ural arteriovenous fistulas are most often able to be treated by endovascular therapy, avoiding the need for surgery. The devel- opment of transvenous routes to these lesions has further expanded the role of endovascular therapy. As this video demonstrates, there remain OPERATIVE NEUROSURGERY VOLUME 15 | NUMBER 3 | SEPTEMBER 2018 | 353 Downloaded from https://academic.oup.com/ons/article/15/3/353/4772692 by guest on 03 December 2021