PMC8202377_01
(a) Preoperative magnetic resonance imaging: Axial T2 SPACE image at the level of inferior pons showing ill-defined vasogenic edema with multiple microbleeds involving the left cerebellum with extension to the middle cerebellar peduncle. (b) Preoperative magnetic resonance imaging: Arrow indicates tortuous hypertrophied vascular channel at the right fifth nerve root entry zone. (c) Preoperative magnetic resonance imaging: Sagittal T2 image of the cervical spine showing long segment cord signal changes with prominent perimedullary veins
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F1
A detailed neurological examination revealed hypersensitivity at V2 and V3 divisions of the fifth nerve [Figure 1], along with spastic quadriparesis noted on motor examination.
(a) Preoperative digital subtraction cerebral angiogram of the right internal carotid artery in anteroposterior projection shows cognard Type 5 dural arteriovenous fistula (arrow) supplied by the meningohypophyseal trunk with venous drainage into the tentorial vein and perimedullary veins.(b) Preoperative digital subtraction angiography, lateral projection of the internal carotid artery shows dural arteriovenous fistula marked by arrow. (c) Preoperative digital subtraction angiography: Right external carotid angiogram in lateral projection shows the absence of external carotid artery feeders
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F2
Patchy enhancement was seen along the cervical spinal cord with multiple prominent perimedullary veins up to the conus level and dilated tortuous right inferior hypophyseal trunk [Figure 2].
(a and b) Intraoperative image: (a) Trigeminal nerve. (b) Arterialized superior petrosal vein. (c) Seventh and eighth nerve complex. (d) Labyrinthine artery. (e) Subarcuate artery. (f) Fistulous vein curving around the fifth nerve. (g) Pledget between the fifth nerve and the fistulous vein. (c) Intraoperative image: (a) Trigeminal nerve. (b) Arterialized superior petrosal vein. (c) Seventh and eighth nerve complex. (d) Labyrinthine artery. (e) Subarcuate artery. (f) Fistulous vein curving around the fifth nerve. (g) Pledget between the fifth nerve and the fistulous vein. Showing clipped fistulous vein by curved sugita clip and superior petrosal vein by straight clip
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F3
A digital subtraction angiography (DSA) was done which showed right DAVF surrounding the cisternal segment of the right trigeminal nerve with arterial supply from the meningohypophyseal trunk-single feeder branch artery and venous drainage through the superior petrosal vein into the superior petrosal sinus [Figure 3].
Postoperative digital subtraction cerebral angiogram of the right common carotid artery in anteroposterior projection shows complete obliteration of fistula. (b) Postoperative digital subtraction cerebral angiogram of the right common carotid artery in lateral projection shows complete obliteration of fistula
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F4
Follow-up [Figure 4] DSA after 1 week showed complete obliteration of the fistula.