Imaging of Cerebral Arteriovenous Malformations and Arteriovenous Fistulas and Occlusion Control Using Intraoperative 3-Dimensional Rotational Fluoroscopy

Abstract

Intraoperative resection or occlusion control is indispensable in the surgery of vascular anomalies. This can be conducted using local vascular imaging modalities or angiographic techniques. This series was performed to assess whether cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulae (dAVFs) can be detected in a sufficient quality by intraoperative 3-dimensional (3D) fluoroscopy with intravenous contrast application. Five patients were included in the analysis (2 AVMs, 3 dAVFs). All patients had preoperative digital subtraction angiography. The head was fixed in a carbon MAYFIELD clamp. After a 3D rotational fluoroscopy scan without contrast agent, a second scan with 50 mL of iodine contrast agent was performed. The Digital Imaging and Communications in Medicine data of both scans were subtracted and reconstructed using the OsiriX imaging software. In 2 patients with dAVF, occlusion control was performed after obliteration of the fistula. In the 2 patients with cerebral AVM, 3D fluoroscopy with intravenous contrast administration resulted in good image quality. Preoperative embolization with Onyx produces significant artifacts that can be largely removed by simple digital subtraction techniques. In dural AVF, occlusion control was well feasible after obliteration of the draining vein at its dural origin. This technique quickly supplies intraoperative images of adequate quality to locate cerebral AVM and dAVF. However, it does not produce dynamic images. Thus, early draining veins cannot be located unless anatomically identified based on the preoperative DSA. In this case, it can be used for intraoperative obliteration control.