Temporary clamping of bilateral external carotid arteries for surgical excision of a complex dural arteriovenous fistula
A 48-year-old male presented with chronic headache, which he had suffered for several years, with pulsatile bruit sound over the bilateral ears. Neurological examination revealed no specific neurological deficit. CT angiography of the brain revealed no intracranial hemorrhage but did show numerous engorged vessels in bilateral cerebral hemisphere and superficial scalp. DSA showed DAVFs, Cognard type IIb, in sagittal-torcular region with numerous arterial feeders from bilateral ECAs with cerebral venous reflux [Figure and ]. It is risky to excise fistulas involving torcular region so surgical excision of arterial feeders and skeletonization of diseased sinus as possible was planned. The purpose of surgery is to reduce abnormal shunting flow and to prepare for further endovascular embolization or radiosurgery while identifying the exact fistula well. Using temporary clamping of bilateral ECAs, the partial excision of the complex DAVFs became easy [Figure and ]. Later, transarterial embolization (TAE) with Onyx (ev3, Irvine, California) was performed to obliterate the residual DAVFs successfully. The mRS was also zero at discharge.