Microsurgical treatment of a posterior fossa arteriovenous malformation initially mistaken for a dural arteriovenous fistula: avoidance of near disaster.

Brian M Howard,Daniel L Barrow

doi:10.3171/2020.10.focvid2047

Brian M Howard, Daniel L Barrow

Open Access

https://doi.org/10.3171/2020.10.focvid2047

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Journal: Neurosurgical focus: Video	Publication Date: Jan 1, 2021
Citations: 1	License type: CC BY 4.0

Affiliation: Emory University

Abstract

Many brain arteriovenous malformations (AVMs) derive dural blood supply, while 10%–15% of dural arteriovenous fistulas (dAVFs) have pial arterial input. To differentiate between the two is critical, as treatment of these entities is diametrically opposed. To treat dAVFs, the draining vein(s) is disconnected from feeding arteries, which portends hemorrhagic complications for AVMs. The authors present an operative video of a subtle cerebellar AVM initially treated as a dAVF by attempted embolization through dural vessels. The lesion was subsequently microsurgically extirpated. The authors show a comparison case of an AVM mistaken for a dAVF and transvenous embolization that resulted in a fatal hemorrhage.The video can be found here: https://youtu.be/eDeiMrGoE0Q

Highlights

The case is that of an otherwise healthy 18-year-old patient who presented to a referring facility with acute-onset worst headache of life associated with emesis and diplopia
Key considerations for this case include the differential diagnosis for cerebellar intraparenchymal hemorrhage with an emphasis on diagnostic accuracy to ensure that the appropriate therapeutic modality is employed
The right external carotid artery injection elicited concern that the middle meningeal artery contributed to the arteriovenous malformation

Summary

Introduction

The case is that of an otherwise healthy 18-year-old patient who presented to a referring facility with acute-onset worst headache of life associated with emesis and diplopia. Axial imaging demonstrated a right cerebellar hemispheric intraparenchymal hemorrhage. Key considerations for this case include the differential diagnosis for cerebellar intraparenchymal hemorrhage with an emphasis on diagnostic accuracy to ensure that the appropriate therapeutic modality is employed. Right vertebral angiography demonstrates a subtle shunting lesion with a nidus in the superior aspect of the right cerebellar hemisphere at the petrosal surface [open arrow] with hemispheric cortical venous drainage to the superior petrosal vein [solid arrows].

Results

Conclusion