Microsurgical Treatment of a Complex Cognard V Tentorial Dural Fistula with Superior Cerebellar Artery Supply

Microsurgical Treatment of a Complex Cognard V Tentorial Dural Fistula with Superior Cerebellar Artery Supply:



Publication date: Available online 17 October 2020

Source: World Neurosurgery

Author(s): Ryan Dimentberg, Svetlana Kvint, Peter Madsen, Gregory Glauser, Omar Choudhri



Abstract

This case video demonstrates a microsurgical technique for the clipping and obliteration of a Cognard V tentorial dural fistula. The patient was a 49-year-old male who presented with progressive upper and lower extremity weakness over 12 months, with associated cervical spinal cord edema. The patient was initially misdiagnosed with transverse myelitis, however abnormal flow voids on the MRI led to a cerebral angiogram being performed. The pre-operative angiogram demonstrated the Cognard V right tentorial dural arteriovenous fistula with drainage into the dorsal and ventral medullary veins. The fistula resulted in spinal cord symptoms due to spinal cord venous engorgement, with a lack or cranial symptoms. In these cases, microsurgery is the preferred method of treatment due to excellent surgical window to the medial tentorial margin and difficulty in catheterizing the small tortuous superior cerebellar artery meningeal feeder. This is a novel case showing a hybrid operating room technology to safely approach a complex fistula and obtain curative confirmation by transradial intraoperative angiography. In addition, this case is unique in providing a surgical visualization of the meningeal superior cerebellar artery feeder contributing to this fistula, namely the artery of Wollschlaeger & Wollschlaeger. Post-operatively, the patient demonstrated significant improvement in upper and lower extremity strength, indicative of a successful recovery. The patient was discharged to rehabilitation, with continued motor improvement.



Keywords

dural fistulaspinal cordcerebrovascularmicrosurgery