Clipping of High-Risk Dural Arteriovenous Fistula of the Posterior Fossa: 3-Dimensional Operative Video

Abstract

Dural arteriovenous fistulas (DAVFs) represent 10%-15% of all intracranial arteriovenous malformations.¹ DAVFs located in the posterior cranial fossa are rare and often present with intracranial hemorrhage and myelopathy.² Arterial supply could be provided by the meningeal branches of the vertebral artery and external and internal carotid arteries.³ A 68-year-old man presented with progressive lower-extremity weakness (Video 1). Magnetic resonance imaging revealed a patchy longitudinal cord signal abnormality extending from the cervicomedullary junction to C7. A tentorial DAVF supplied by the right posterior meningeal artery with drainage via dorsal and ventral perimedullary veins was identified on angiography. According to the Cognard classification, the patient's DAVF was determined to be high risk as a type V lesion with spinal venous drainage and progressive myelopathy.⁴ The fistula was embolized with 50% ethanol resulting in near-complete occlusion. However, follow-up angiography revealed a persistent arteriovenous shunt and slightly worsening symptoms for the patient. He underwent a sitting supracerebellar approach with a torcular craniotomy for successful clip ligation of the dural arteriovenous fistula. The patient was discharged with improvements in lower-extremity strength and no residual arteriovenous shunting in postoperative imaging.

Keywords: 3D video; Dural arteriovenous fistula; Myelopathy; Perimedullary veins; Posterior fossa; Posterior meningeal artery; Supracerebellar approach.