Abstract
Background
Dural arteriovenous fistulas (dAVFs) at the superior petrosal sinus are a rare but important subtype that pose a high risk of mortality and morbidity. Treatment for these lesions can be challenging with stand-alone endovascular methods.
Methods
We describe our “in-out-in” technique for disconnecting dAVFs at the superior petrosal sinus, which includes definitive sacrifice of the superior petrosal sinus and the transverse sigmoid sinus, if involved. This method achieves complete fistula obliteration and minimizes recurrence risk with new arterial feeders.
Conclusions
The in-out-in technique is a safe and effective approach for the treatment of dAVFs involving the superior petrosal sinus.
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Data availability
All data are presented in the paper.
Code availability
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References
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Acknowledgements
We thank Vance Mortimer for assistance in preparing the surgical video and Kristin Kraus for editorial assistance.
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Authors and Affiliations
Contributions
Ramesh Grandhi: methodology, writing — original draft, visualization.
Cameron Rawanduzy: methodology, writing — original draft, visualization.
Robert C. Rennert: methodology, writing — original draft, visualization.
William T. Couldwell: conceptualization, resources, supervision, project administration, writing — review and editing.
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Approval from the institutional review board is waived for case reports. All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Utah and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Key points
• dAVFs of the SPS are an uncommon but morbid subtype of cranial dAVF.
• SPS dAVFs often present with symptoms of myelopathy or hemorrhage.
• CVR indicates a high-risk dAVF.
• T2/FLAIR abnormalities may suggest an aggressive nature of the dAVF and indicate treatment.
• Endovascular embolization is challenging in dAVFs involving the SPS.
• Sacrifice of the TSS junction and SPVC, in addition to the fistulous outflow, prevents recurrence.
• Preoperative digital subtraction angiography is essential to understand the arterial supply and venous drainage of the fistula.
• The SPVC draining patterns should be understood preoperatively.
• Use of video angiography and neuromonitoring can ensure safe ligation of the fistula intraoperatively.
• The goals of surgery and the possibility of symptom relief should be discussed in depth with the patient.
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Rawanduzy, C.A., Grandhi, R., Rennert, R.C. et al. In-out-in technique for petrosal sinus dural arteriovenous fistula obliteration: How I Do It. Acta Neurochir 165, 3793–3798 (2023). https://doi.org/10.1007/s00701-023-05822-0
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DOI: https://doi.org/10.1007/s00701-023-05822-0