Authors: V I Vougioukas C J Coulin M Shah A Berlis U Hubbe V Van Velthoven
Publish Date: 2005/12/07
Volume: 148, Issue: 2, Pages: 145-
Abstract
Background Despite major advances in endovascular embolization techniques microsurgical resection remains a reliable and effective treatment modality for dural arteriovenous fistulas DAVF However intraoperative detection of these lesions and identification of feeding arteries and draining veins can be challenging In a series of 6 patients who were not candidates for definitive treatment by endovascular embolization we evaluated the benefits and limitations of computerassisted image guidance for surgical ablation of DAVFMethods Of the 6 patients 5 presented with haemorrhage and one with seizures Diagnosis of DAVF was made by conventional angiography and dynamic contrast enhanced MR angiography CEMRA All patients were surgically treated with the assistance of a 3D high resolution T1weighted MR data set and timeofflight MR angiography MRA obtained for neuronavigation Registration was based on cranial fiducials and imageguided surgery was performed with the navigation systemFindings Four of the 6 patients suffered from DAVF draining into the superior sagittal sinus one fistula drained into paracavernous veins adjacent to the superior petrosal sinus and one patient had a pial fistula draining in the straight sinus DAVF diagnosed with conventional angiography could be located on CEMRA and MRA prior to surgery MRI and MRA images were combined on the neuronavigation workstation and DAVF were located intraoperatively by using a tracking device In 4 out of 6 cases neuronavigation was used for direct intraoperative identification of DAVF Brain shift prevented direct tracking of pathological vessels in the other 2 cases where navigation could only be used to assist craniotomy Microsurgical dissection and coagulation of the fistulas led to complete cure in all patients as confirmed by angiographyConclusions Neuronavigation may be used as an additional tool for microsurgical treatment of DAVF However in this small series of 6 cases surgical procedures have not been substantially altered by the use of the neuronavigation system Image guidance has been beneficial for the location of small superficially located DAVF whereas a navigated approach to deepseated lesions was less accurate due to the familiar problem of brain shift and brain retraction during surgery
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