Extreme lateral supracerebellar infratentorial approach for tentorial arteriovenous fistula associated with a giant venous ectasia: how I do it

Kyriakos Papadimitriou,Amani Belouaer,Roy Thomas Daniel,Daniele Starnoni

doi:10.1007/s00701-021-04945-6

Kyriakos Papadimitriou, Amani Belouaer + Show 2 more

Open Access

https://doi.org/10.1007/s00701-021-04945-6

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Journal: Acta Neurochirurgica	Publication Date: Aug 13, 2021
Citations: 2	License type: open-access

Affiliation: University of Lausanne

Abstract

BackgroundSurgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space. Interruption of the arterialized vein requires a good knowledge of the regional anatomy and a precise preoperative evaluation.MethodsWe describe the key steps extreme lateral supracerebellar infratentorial (ELSI) approach for tentorial DAVF with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach.ConclusionsIn cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes.

Highlights

Surgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space
A more inferior and medial retraction of the quadrangular lobule of the cerebellum can expand the exposure of the cerebellomesencephalic fissure and the cerebellopontine cistern
In cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, extreme lateral supracerebellar infratentorial (ELSI) offers an excellent surgical exposure

Summary

Relevant surgical anatomy

The extreme lateral supracerebellar infratentorial (ELSI) is an excellent approach to access the middle and posterolateral incisural space, which corresponds to the ambient and posterolateral aspect of the quadrigeminal cisterns [9]. A more inferior and medial retraction of the quadrangular lobule of the cerebellum can expand the exposure of the cerebellomesencephalic fissure and the cerebellopontine cistern This lateral cerebellar corridor, combined with the supracerebellar, expands the access to the infratentorial part of the middle incisural space allowing the surgeon to work in two windows, on either side of the superior petrosal vein and the trigeminal nerve. In cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers an excellent surgical exposure

How to avoid complications

Preoperative workup

Postoperative workup

Findings

Instructions for the postoperative care