Resection of a giant intracranial dural arteriovenous fistula with the useof low-flow deep hypothermic cardiopulmonary bypass after partial embolization: Technical case report

OBJECTIVE AND IMPORTANCE: To describe the surgical resection of a giant int racerebral arteriovenous fistula with involvement of dura mater and surroun ding bone. Intraoperative bleeding was controlled by hypothermic circulator y arrest. CLINICAL PRESENTATION: This 46-year-old woman complained of persistent head ache for 1 year; her diagnostic workup revealed the presence of an arteriov enous fistula in the dura mater of the left temporal region fed by the meni ngeal artery of the external and internal carotid arteries, with normal run -off into Labbe's and Trolard's veins. Magnetic resonance imaging depicted a Chiari I malformation that was most likely a result of insufficient cereb ral venous drainage. INTERVENTION: In preparation for surgery, staged embolization of feeders fr om the left meningeal artery and the left occipital artery was performed un der controlled hypotension. This procedure failed to achieve a significant reduction in flow because of the immediate recruitment of internal branches of the internal carotid artery and dural branches of the right external ca rotid artery. Surgical treatment was undertaken without further embolizatio n. Because of involvement of surrounding bone and the high risk of uncontro llable bleeding, the procedure was carried out with the patient under deep hypothermic cardiopulmonary bypass. Forty-five minutes of low flow (1.5 L/m in) at 18 degreesC allowed total resection of the involved dura mater and s urrounding bone. Postoperative recovery was marked by left brain edema that disappeared within 10 days. findings on follow-up angiography were normal, and the patient was discharged with no neurological deficit. CONCLUSION: Low-flow deep hypothermic cardiopulmonary bypass can be used to control intraoperative bleeding for surgical excision of a giant intracere bral dural arteriovenous fistula.