Ruptured Tentorial Arteriovenous Fistula: Endoscopic-Assisted Microsurgical Disconnection Using Indocyanine Green Videoangiography Guidance

Tentorial dural arteriovenous fistulas are rare causes of intracranial hemorrhage and nervous tissue venous congestion. Due to their extensive arterial supply and difficult transvenous endovascular navigation, they are frequently managed microsurgically. Precise identification of the venous drainage, its retractorless exposition, and real-time verification of arteriovenous disconnection are the mainstays of surgery. We describe the case of 61-year-old man presenting with a cerebellar hematoma causing obstructive hydrocephalus, resolved by emergent endoscopic third ventriculocisternostomy, with no need of external ventricular drain.1 Brain angiograms showed a straight sinus dural arteriovenous fistula. The fistulous point could not be reached endovascularly due to the small caliber and tortuosity of the arterial feeders and difficult transvenous navigation, and then the endovascular treatment was limited to closure of both occipital arteries. At surgery, indocyanine green videoangiography with semiquantitative assessment of flow dynamics identified the draining vein originating from the dura of the left wall of the straight sinus (Video 1). After the draining vein was clipped at its origin from the straight sinus and the endoscopic view confirmed that the clip's tips straddled the vein, control indocyanine green videoangiography showed no more early injection of the draining vein and restoration of the normal venous drainage. Postoperative angiograms confirmed the elimination of the fistula. The patient was discharged to a rehabilitation facility 5 days postoperatively and regained functional independence, with a modified Rankin Scale score of zero by the third month after surgery. Relevant teaching points are exposed at the end of the case narration.