Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
Neurol India. 2021 Nov-Dec;69(6):1554-1556. doi: 10.4103/0028-3886.333526.
Dural arteriovenous fistulas (dAVFs) are a rare pathology with a clinical presentation related to their anatomical location. Craniocervical junction (CCJ) dAVFs are challenging to treat given the delicate structures that surround the CCJ. Endovascular treatment has evolved significantly in the past decade, but open microsurgery remains an invaluable tool for this pathology.
To demonstrate the step-by-step elements of the far lateral approach for microsurgical ligation of CCJ dAVF.
A retroauricular incision is created, extending down the neck, and the suboccipital triangle muscles are dissected, exposing the posterior arch of C1. The vertebral artery (VA), as well as its entrance point in the dura, is also dissected and exposed. Next, a C1 hemilaminectomy is performed, followed by a suboccipital craniectomy and drilling of the posteromedial portion of the condyle. The dura is opened behind the VA entrance in the dura, and the intradural VA is exposed. Once the fistula is identified, a temporary clip is placed on the draining vein. Indocyanine green video angiography is used to confirm that there is no further connection; the clip is then removed and the fistula obliterated. The dura is closed in a watertight fashion with a fat bolster to prevent a pseudomeningocele.
Postoperative angiogram showed complete resolution of the pathology. The patient was discharged neurologically intact on postoperative day 4.
Microsurgical obliteration of CCJ dAVFs can be achieved safely and efficiently through a far lateral approach.
硬脑膜动静脉瘘（dAVF）是一种罕见的病理学，其临床表现与其解剖位置有关。颅颈交界区（CCJ）的 dAVF 由于其周围结构的精细，治疗起来具有挑战性。在过去的十年中，血管内治疗有了显著的发展，但开放显微手术仍然是治疗这种病理学的宝贵工具。
展示显微外科结扎 CCJ dAVF 的远外侧入路的分步要素。
在耳后做一个切口，向下延伸到颈部，然后分离枕下三角肌肉，暴露 C1 的后弓。椎动脉（VA）及其在硬脑膜中的入口也被解剖和暴露。接下来，进行 C1 半椎板切除术，然后进行枕下颅骨切除术和髁突后内侧钻孔。硬脑膜在 VA 入口处的硬脑膜后面打开，暴露颅内 VA。一旦确定瘘管，就在引流静脉上放置一个临时夹。吲哚菁绿视频血管造影用于确认没有进一步的连接；然后移除夹子并使瘘管闭塞。硬脑膜以水密方式用脂肪垫闭合，以防止假性脑膜膨出。
术后血管造影显示病变完全缓解。患者在术后第 4 天神经功能完整出院。
通过远外侧入路可以安全有效地进行 CCJ dAVF 的显微外科闭塞。
