Use of frameless stereotactic computed tomography venography for intraoperative localization of dural arterial venous fistulas: case report

Background: The following technical case report illustrates the use of multiple imaging modalities including 3D CTV with frameless stereotactic navigation for intraoperative planning and localization for surgical obliteration of a cranial dAVF with leptomeningeal drainage. Case Description: This 65-year-old man presented with an asymptomatic occipital dAVF with leptomeningeal drainage. In addition to cerebral angiography, a CTV with 3D reconstruction was performed, which provided excellent visualization of the dAVF and clarified its pattern of drainage. The dAVF was supplied by a middle meningeal artery branch that drained into an occipital cortical vein, which then retrograde filled the vein of Labbé. Frameless stereotactic navigation with the imported CTV images was used to plan the craniotomy and to localize the leptomeningeal draining vein and vein of Labbé. The draining vein of the fistula was successfully ligated and divided while preserving flow in the vein of Labbé. Postoperative angiogram demonstrated complete obliteration of the dAVF. Conclusion: Integration of a 3D reconstructed CTV with conventional angiographic information optimized our surgical understanding of the spatial anatomy of this dAVF and its pattern of venous drainage. Applying the CTV with frameless stereotaxy allowed for safe obliteration of the dAVF while preserving the vein of Labbé.