J Cerebrovasc Endovasc Neurosurg.  2023 Dec;25(4):440-446. 10.7461/jcen.2023.E2022.12.004.

Iatrogenic mixed pial and dural arteriovenous fistula after pterional approach for surgical clipping of aneurysm: A case report

• Woo SB
• Ko YS
• Lee CY

• KMID: 2549450
• DOI: http://doi.org/10.7461/jcen.2023.E2022.12.004

Abstract

Craniotomy is known as a cause of iatrogenic dural cerebral arteriovenous fistula (AVF). However, mixed pial and dural AVFs after craniotomy are extremely rare and require accurate diagnosis and prompt treatment due to their aggressiveness. We present a case of an iatrogenic mixed pial and dural AVF diagnosed 2 years after pterional craniotomy for surgical clipping of a ruptured anterior choroidal aneurysm. The lesion was successfully treated using single endovascular procedure of transvenous coil embolization through the engorged vein of Labbe and the superficial middle cerebral vein. The possibility of the AVF formation after the pterional approach should always be kept in mind because it usually occurs at the middle cranial fossa, which frequently has an aggressive nature owing to direct cortical venous or leptomeningeal drainage patterns. This complication is believed to be caused by angiogenetic conditions due to coagulation, retraction, and microinjuries of the perisylvian vessels, and can be prevented by performing careful sylvian dissection according to patient-specific perisylvian venous anatomy.

Keyword

Arteriovenous fistula; Craniotomy; Iatrogenic; Mixed pial and dural

Figure

• 

  Fig. 1. (A) Contrast-enhanced computed tomography (CT) scan showing venous ectasias beneath the previous left craniotomy site (black arrow). (B) Three-dimensionally reconstructed CT angiography demonstrating suspicious dual arteriovenous fistula with multiple feeders from pial arteries (black arrow) and dural arteries (white arrow). Cortical venous reflux and venous hypertension is suspected (arrowhead).

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  Fig. 2. (A) Left external carotid artery angiography demonstrating multiple feeders from the middle meningeal artery and superficial temporal artery. Drainage pattern to engorge the superficial middle cerebral vein (black arrow) and vein of Labbe (white arrow) is noted. (B, C) Left internal carotid artery angiography showing additional multiple pial arterial feeders arising from the middle cerebral artery (black arrow).

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  Fig. 3. (A, B) Intraoperative angiography showing microcatheter advancement to the fistulous point (black arrow), superficial middle cerebral vein (SMCV), via sigmoid sinus and vein of Labbe (white arrow). (C) Coil embolization of SMCV was performed.

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  Fig. 4. (A) Postoperative lateral radiograph demonstrating fulfilled coils to the fistulous point. (B, C) Postoperative internal carotid artery and external carotid artery angiography showing occlusion of the arteriovenous shunt.

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