Rubio Roberto R, Chae Ricky, Dubnicoff Todd, Winkler Ethan, Abla Adib A
Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, United States.
Department of Neurological Surgery, University of California, San Francisco, California, United States.
J Neurol Surg B Skull Base. 2021 Feb;82(Suppl 1):S43-S44. doi: 10.1055/s-0040-1705162. Epub 2020 Nov 5.
Dural arteriovenous fistulas (DAVFs) at the cervicomedullary junction are uncommon and often accompanied by subarachnoid hemorrhage (SAH). We aim to illustrate in detail the microsurgical procedure for treating a DAVF located at the cervicomedullary junction. We present a two-dimensional operative video that includes clinical history, preoperative imaging, surgical strategy, still images with labels, clinical course, and postoperative imaging. The microsurgery was performed at an academic medical center. The patient is a 55-year-old female who presented with SAH, acute onset headache, nausea, and vomiting. Angiography demonstrated right vertebral artery vasospasm and a persistent arteriovenous shunt at the cervicomedullary junction supplied by small perforating arteries of the right vertebrobasilar junction ( Fig. 1 ). The patient was placed in the park-bench position with the head turned to the contralateral side. A hockey stick incision was made, followed by a right-side far-lateral transcondylar approach. Indocynanine green videoangiography was performed to help identify the areas of arteriovenous shunting. Multiple clips were placed to interrupt vessels that corresponded to arterial feeders at the level of the C1 and C2 nerve root sleeves ( Fig. 2 ). The dura was closed in a water tight fashion and the posterior fossa was reconstructed with a titanium mesh. Postoperative imaging showed no evidence of continued arteriovenous shunting. The patient was discharged in good clinical condition with an uneventful postoperative course. A deep understanding of the microsurgical vascular anatomy is necessary for successful occlusion of a cervicomedullary DAVF. The link to the video can be found at: https://youtu.be/-LfOcNB05BY .
颈髓交界处的硬脑膜动静脉瘘（DAVF）并不常见，且常伴有蛛网膜下腔出血（SAH）。我们旨在详细阐述治疗位于颈髓交界处的DAVF的显微外科手术过程。
我们展示了一段二维手术视频，内容包括临床病史、术前影像学检查、手术策略、带标注的静态图像、临床病程以及术后影像学检查。
显微手术在一家学术医疗中心进行。
患者为一名55岁女性，表现为SAH、急性起病的头痛、恶心和呕吐。血管造影显示右椎动脉痉挛以及由右椎基底动脉交界处的小穿支动脉供血的颈髓交界处存在持续性动静脉分流（图1）。
患者置于公园长椅体位，头转向对侧。做了一个曲棍球棒状切口，随后采用右侧远外侧经髁入路。进行吲哚菁绿视频血管造影以帮助识别动静脉分流区域。在C1和C2神经根袖水平放置多个夹子以阻断与动脉供血支相对应的血管（图2）。硬脑膜以水密方式缝合，后颅窝用钛网重建。
术后影像学检查显示无持续动静脉分流的迹象。患者临床状况良好出院，术后病程顺利。
要成功闭塞颈髓DAVF，深入了解显微外科血管解剖结构是必要的。视频链接可在：https://youtu.be/-LfOcNB05BY 找到。
