Far Lateral Craniotomy for Obliteration of High-Risk Craniocervical Junction Arteriovenous Fistula.

[BACKGROUND AND INTRODUCTION] Dural arteriovenous fistulas (dAVFs) are a rare pathology with a clinical presentation related to their anatomical location. Craniocervical junction (CCJ) dAVFs are challenging to treat given the delicate structures that surround the CCJ. Endovascular treatment has evolved significantly in the past decade, but open microsurgery remains an invaluable tool for this pathology.

[OBJECTIVE] To demonstrate the step-by-step elements of the far lateral approach for microsurgical ligation of CCJ dAVF.

[SURGICAL TECHNIQUE] A retroauricular incision is created, extending down the neck, and the suboccipital triangle muscles are dissected, exposing the posterior arch of C1. The vertebral artery (VA), as well as its entrance point in the dura, is also dissected and exposed. Next, a C1 hemilaminectomy is performed, followed by a suboccipital craniectomy and drilling of the posteromedial portion of the condyle. The dura is opened behind the VA entrance in the dura, and the intradural VA is exposed. Once the fistula is identified, a temporary clip is placed on the draining vein. Indocyanine green video angiography is used to confirm that there is no further connection; the clip is then removed and the fistula obliterated. The dura is closed in a watertight fashion with a fat bolster to prevent a pseudomeningocele.

[RESULTS] Postoperative angiogram showed complete resolution of the pathology. The patient was discharged neurologically intact on postoperative day 4.

[CONCLUSIONS] Microsurgical obliteration of CCJ dAVFs can be achieved safely and efficiently through a far lateral approach.