case_images: PMC11794442_01
case_images: (A) Preoperative head CT, (B) CTA and (C, D) DSA identified the fistula (arrows) in the left lateral dural membrane and confirmed the intradural origin of the drainage vein.
case_images: rjaf021f1.jpg
case_images: PMC11794442_01_rjaf021f1.jpg
case_images: f1
case_images: SAH predominantly in the posterior fossa, which was around the medulla oblongata, in the prepontine cistern and interpeduncular cistern (Fig. 1A). The following CT angiography (CTA) showed an abnormal vascular structure around the C1, but the image was not clear (Fig. 1B). Further digital subtraction angiography (DSA) revealed an arteriovenous fistula located at the C2 level, supplied by a branch of the left vertebral artery (Fig. 1C and D).
case_images: (A) Intraoperative ICG fluorescence imaging demonstrated that the fistula and abnormal drainage vein (asterisk) developed earlier than the posterior inferior cerebellar artery (PICA). (B) Coagulation of the origin of the abnormal drainage vein. (C) A subsequent ICG imaging confirmed the absence of fistula and drainage vein (asterisk) filling, with previously drainage veins developing later than the vertebral artery and PICA.
case_images: rjaf021f2.jpg
case_images: PMC11794442_01_rjaf021f2.jpg
case_images: f2
case_images: Intraoperative indocyanine green (ICG) videoangiography was performed to identify the proximal draining vein, which was filled early with the ICG (Fig. 2A). Then we coagulated the abnormal vein close to the dural (Fig. 2B). Then the arterialized veins were darked in ICG videoangiography (Fig. 2C), preserving the draining veins to avoid spinal cord ischemia.
case_images: Postoperative DSA (A) confirmed the complete occlusion of the fistula (arrow) when compared with the preoperative DSA (B).
case_images: rjaf021f3.jpg
case_images: PMC11794442_01_rjaf021f3.jpg
case_images: f3
case_images: Postoperative DSA confirmed complete obliteration of the fistula, and the patient had an uneventful recovery (Fig. 3).