- Department of Surgery, Tri-Service General Hospital Songshan Branch, Taipei, Taiwan
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
Department of Neurosurgery, Taichung Veterans General Hospital, Taichung, Taiwan
DOI:10.4103/2152-7806.125780Copyright: © 2014 Shen SC. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shen S, Chen W, Chen S, Sun M, Shen C, Tsuei Y. Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula. Surg Neurol Int 23-Jan-2014;5:10
How to cite this URL: Shen S, Chen W, Chen S, Sun M, Shen C, Tsuei Y. Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula. Surg Neurol Int 23-Jan-2014;5:10. Available from: http://sni.wpengine.com/surgicalint_articles/temporary-clamping-of-bilateral-external-carotid-arteries-for-surgical-excision-of-a-complex-dural-arteriovenous-fistula/
Background:Some complex dural arteriovenous fistulas (DAVFs) are lesions that typically have numerous arterial feeders. Surgery, including resection of fistulas or skeletonization of the diseased sinus, is still one of the important treatments for these lesions. However, major blood loss is usually encountered during craniotomy because of abundant arterial feeders from the scalp and transosseous vessels. We present a novel approach for obliteration of the fistulas with less blood loss.
Methods:Our first case was a 52-year-old male who suffered from syncope and seizure. Cerebral digital subtraction angiography (DSA) revealed complex DAVFs with numerous arterial feeders from bilateral external carotid arteries (ECAs) and drainage into the superior sagittal sinus with cerebral venous reflux. The second case was a 48-year-old male presenting with chronic headache. His DSA also showed complex DAVFs along the superior sagittal sinus with cerebral venous reflux. In both cases, we performed the surgical procedure to obliterate the pathological fistulas after temporary clamping of bilateral ECAs and noted less blood loss than in the conventional surgery.
Results:The follow-up DSA showed successful obliteration of the complex DAVFs on the first case and partial improvement on the second case followed by transarterial embolization (TAE). The symptoms of the both patients were relieved after surgery with good recovery.
Conclusion:Temporary clamping of bilateral ECAs can improve the safety and ease the surgical excision for complex DAVFs. By using this technique, neurosurgeons can deal with aggressive DAVFs more confidently and calmly.
Keywords: Dural arteriovenous fistula, external carotid arteries, temporary clamping
Surgical excision of complex dural arteriovenous fistulas (DAVFs) usually encounters massive blood loss during the skull approach because of abundant scalp and transosseous feeders mainly from branches of bilateral external carotid arteries (ECAs).[
A 52-year-old male presented with head heaviness and headache, which he had for 3 weeks. He was sent to our emergency room due to his syncope and seizure. Computed tomography (CT) angiography of the brain revealed no intracranial hemorrhage but did show numerous engorged vessels in bilateral cerebral hemisphere and superficial scalp. However, digital subtraction angiography (DSA) showed numerous arterial feeders from the bilateral parietal-occipital scalp and dura, which shunted into superior saggital sinus with cerebral venous reflux, compatible with DAVFs, Cognard type IIb [Figure
(a) Preoperative angiograms of right ECAs; (b) left ECAs showing numerous and tortuous arterial feeders and DAVFs along superior sagittal sinus in case 1; (c) Preoperative angiograms of right ECAs; (d) left ECAs showing numerous and tortuous arterial feeders, superior sagittal sinus and torcular DAVFs in case 2; (e and f) total obliteration of fistulas after surgery in case 1; (g and h) showing obliteration of DAVF at superior sagittal sinus but residual DAVFs near torcular area after surgery in case 2
A 48-year-old male presented with chronic headache, which he had suffered for several years, with pulsatile bruit sound over the bilateral ears. Neurological examination revealed no specific neurological deficit. CT angiography of the brain revealed no intracranial hemorrhage but did show numerous engorged vessels in bilateral cerebral hemisphere and superficial scalp. DSA showed DAVFs, Cognard type IIb, in sagittal-torcular region with numerous arterial feeders from bilateral ECAs with cerebral venous reflux [Figure
Both cases received surgical intervention for their complex DAVFs in the hybrid operating room equipped with Artis Zeego multi-axis system (Siemens, Germany). The patient was placed in a supine position with head raised about 30 degrees. Then, an angiographic catheter was inserted into the right femoral artery for intraoperative DSA first. Skin sterilization and draping were prepared over both the neck and the vertex. Before the craniotomy was performed over the bilateral parietal region, bilateral ECAs were isolated surgically [
High-grade intracranial DAVFs, which were classified into Borden type II and III[
Temporary clamping bilateral ECAs has been used for surgery of convexity and parasagittal meningiomas,[
A limitation of our report is that we just completely obliterated all fistulas primarily on our first case, but the second did not. Residual DAVFs involving the sagittal-torcular region on the second case was identified by postoperative cerebral angiogram [
Thus, we conclude that temporary clamping of bilateral ECAs can improve the safety and ease the surgical excision for complex DAVFs. There also may be economic advantages because of the reduction in blood transfusion and length of hospital stay. By using this technique, neurosurgeons can deal with aggressive DAVFs more confidently and calmly.
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