Name:
10.3171/2025.7.FOCVID2573
Description:
10.3171/2025.7.FOCVID2573
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/97ff85ff-7f44-40bc-8fbf-6af570057e35/videoscrubberimages/Scrubber_237.jpg
Duration:
T00H06M25S
Embed URL:
https://stream.cadmore.media/player/97ff85ff-7f44-40bc-8fbf-6af570057e35
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/97ff85ff-7f44-40bc-8fbf-6af570057e35/8. 25-73.mp4?sv=2019-02-02&sr=c&sig=zFsGt1C6Oc7j3Wjf9O3iD8%2FByg8KACuZeOo4bcE5dsE%3D&st=2026-04-05T09%3A46%3A10Z&se=2026-04-05T11%3A51%3A10Z&sp=r
Upload Date:
2026-04-05T09:51:10.3794809Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: A 40-year-old male with a history of hypertension presented with dizziness, leg weakness, and occasional left-sided facial numbness. 10 months prior to presentation, he experienced an episode of dizziness and leg weakness, along with a bifrontal headache. He reported similar episodes in the past with slight unsteadiness when ambulating. A formal cerebral angiogram prior to the operation documented a dural AV fistula associated with the V3–V4 segment of the left vertebral artery and the C1 nerve root.
SPEAKER: A vascular network was seen surrounding the proximal V4 vertebral artery with venous drainage to the mesencephalic veins, as well as into the occipital sinus with venous congestion. Superselective injection to odontoid arch and left hypoglossal artery did not show arterial contribution to the fistula. 3D reconstruction demonstrated the exact location of the fistula.
SPEAKER: The patient was evaluated for surgical embolization of the vascular lesion. During angiogram, an attempt to engage catheter into the arterial feeder demonstrated in close proximity to the vertebral artery, which did not allow for safe endovascular embolization. Therefore, the decision was made to proceed with surgical intervention. The patient proceeded with C1 laminectomy and midline suboccipital craniectomy for occlusion of dural arteriovenous fistula with intraoperative angiogram.
SPEAKER: The patient was brought to the hybrid operating room and radial access was obtained for intraoperative angiogram. Patient was placed in a prone position. After C1 laminectomy and midline suboccipital craniectomy, the dura was opened approximately 2.5 centimeters in a paramedian fashion to avoid the occipital sinus, which was one of the draining systems of the fistula.
SPEAKER: The dura was tacked up using 2-0 silk sutures. The arachnoid was opened with an arachnoid knife and attached using hemoclips to the dura. The C1 nerve root and accessory nerve were identified along with the vertebral artery. Distal venous outflow was noted. An arterial feeder taking up the dura and attached anterior to the vertebral artery was identified.
SPEAKER: ICG video angiography demonstrated the feeders and the main draining veins. Further dissection revealed the main proximal draining vein between the dentate ligament and the dura. The main draining vein was followed to the level of its entrance to the dura. The most proximal venous outflow of fistulization was identified.
SPEAKER: A temporary clip was placed and an ICG video angiography demonstrated no flow within the distal draining vein.
SPEAKER: A formal diagnostic cerebral angiogram confirmed complete obliteration of the fistulization. The clip was removed and the fistulization was obliterated using bipolar cauterization and separation with scissors. An additional ICG video angiography confirmed no flow into the draining vein.
SPEAKER: Irrigation was performed and hemostasis was achieved. The dura was closed with 6-0 Prolene in a running suture, and Gelfoam and Tisseel glue were placed on top of the dura.
SPEAKER: The muscle was closed with Vicryl sutures and the skin was closed with 3-0 nylon. A drain was placed in the deep muscles, and a superficial JP drain was placed. The patient was extubated and taken to the surgical ICU in stable condition. The patient's postoperative course was uncomplicated. He experienced significant improvement in his symptoms, with no recurrence of the previously noted C1 dural fistula.
SPEAKER: Neurologically, he was at baseline. At the 1-year follow-up, angiography documented complete persistent occlusion of the previously treated fistula with no recurrence. The patient remained symptom free with no new complaints. This case demonstrates the successful surgical management of a complex C1 spinal dural arteriovenous fistula. The C1 laminectomy and midline suboccipital craniectomy approach, combined with meticulous dissection and intraoperative angiography, allows for complete obliteration of the fistula with excellent clinical outcomes.
SPEAKER:
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