Hybrid surgery for dural arteriovenous fistula in the neurosurgical hybrid operating suite

Abstract

SUMMARYTreatment of a dural arteriovenous fistula (AVF), which is difficult to access by either the surgical or endovascular approach, is challenging. A hybrid technique, combining a microsurgical approach and endovascular embolization, can provide less invasive management of dural AVFs in a modern neurosurgical hybrid operating suite. We present a case of intracerebral hemorrhage in the left cerebellum secondary to dural AVF, Cognard type IV with numerous tiny feeders from the ascending pharyngeal artery branches. No adequate arterial or venous route for endovascular embolization was found by neuroangiography. The hybrid technique, combining keyhole pterional craniotomy and embolization with nbutyl cyanoacrylate glue injection via direct cannulation of the periclival venous plexus, succeeded in obliterating the dural AVF. Intraoperative angiography showed successful embolization of the dural AVF without any complication. This report illustrates the usefulness of the neurosurgical hybrid operating suite for the treatment of difficult dural AVFs. BACKGROUND

Surgically treated intracranial arteriovenous fistulas with hemorrhage, resulting in complete obliteration: illustrative cases

“…12 With the development of endovascular treatment devices including liquid embolization materials, the majority of AVFs are successfully treated with endovascular embolization. 5 Transvenous embolization to occlude the proximal draining vein to eliminate the risk of intracranial hemorrhage is also considered in sinus-type AVFs. However, there are cases in which the anatomy prevents endovascular access or in which complete obliteration cannot be achieved.…”

“…3,4 With the recent rise of liquid embolization material, endovascular embolization is preferred in a majority of cases. 5,6 Especially for dural AVFs, transarterial embolization (TAE) with liquid embolization material has recently become the primary treatment. Transvenous coil embolization is still preferred in AVFs with supply from arterial branches supplying cranial nerves, predominant internal carotid artery or vertebral artery (VA) feeders, and potential extracranial-intracranial collateral anastomosis.…”

Superior Sagittal Sinus: A Review of the History, Surgical Considerations, and Pathology

“…Because there is little anatomical variation of the SSS, absence of opacification allows for relative ease in the diagnosis of thrombosis. The venous phase of cerebral angiography is especially useful for visualizing the sinuses [31].…”

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

“…In particular, high-resolution three-dimensional rotational angiography (3DRA) was integrated in the OR to improve the intraoperative diagnostic capabilities [6]. Going beyond intraoperative diagnostic control angiography, various types of combined surgical and endovascular procedures have been performed in single sessions in the hybrid OR [5,11,13,15,23]. Newly developed real-time navigation software merged with cone-beam computed tomography (CBCT) can be used in frameless navigation and in access to deep-seated intracranial lesions [14].…”