{
  "abstract": "Introduction Tentorial dural arteriovenous fistulas (dAVFs) of the cerebellopontine (CP) angle are rare, complex cerebrovascular lesions that present unique difficulties in treatment approaches. Here, we present a Borden Type 3 (Lawton Type V) tentorial dAVF with both internal (ICA) and external carotid (ECA) dural supply, as well as atypical contribution from pial anterior inferior cerebellar artery (AICA) branches, and its successful ligation with good neurologic outcome.Methods A 40-year-old male presented with symptoms of intermittent facial weakness, word-finding difficulty, and mental fog. Diagnostic cerebral angiography confirmed a Borden Type 3 and Lawton Type V, tentorial dAVF with arterial supply from both the ICA (tentorial artery and a recurrent branch of the ophthalmic artery) and ECA (middle meningeal artery) distributions and an unusual supply from pial branches of the ipsilateral AICA. Venous drainage was via the lateral mesencephalic vein into the Vein of Galen, with venous ectasia causing mass effect. Endovascular embolization was considered higher risk due to the numerous tortuous dural arteries supplying the fistula and the pial AICA supply yielding AVM-type characteristics, as incomplete embolization of tentorial dAVFs has shown increased risk of perioperative hemorrhage.Results A retrosigmoid craniotomy and microsurgical approach to the right CP angle was performed. Intraoperative ICG videoangiography demonstrated venous drainage deep to the approach. Careful dissection and ligation of the dural arterial supply anterolaterally was undertaken, followed by the AICA supply posteriorly. Videoangiography and Doppler ultrasonography confirmed obliteration of the arterial inflow, and the ectatic draining vein was clipped. The lesion demonstrated an unusual hybrid vascular structure, with dural arterial feeders from multiple territories, anomalous pial arterial network arising from the ipsilateral AICA, and deep venous drainage into the Vein of Galen. Postoperative angiography confirmed complete ligation with preservation of normal vascular anatomy. The patient recovered without neurologic deficits and with improvement in his symptoms.Conclusion Tentorial dAVFs represent a diverse entity with highly variable vascular architecture requiring tailored management strategies, with possible arterial supply from many territories and venous drainage via either the petrosal or deep venous drainage systems. In this case, given the multitude of arterial feeders including AICA and ophthalmic involvement, and drainage into the Vein of Galen, an open microsurgical approach was selected as endovascular embolization presented significant risks of adverse effects to nearby structures, as well as incomplete obliteration and hemorrhage. Microsurgical ligation achieved both radiographic obliteration of the fistula and an excellent neurologic outcome for the patient.Disclosures D. Lim: None. J. Nerva: 2; C; Medtronic. 4; C; Synchron, Inc, Borvo Medical, Inc, Bendit Technologies, Ltd.Abstract E-145 Figure 1",
  "authors": [
    {
      "affiliations": [
        "Medical College of Wisconsin, Milwaukee, WI"
      ],
      "name": "G Mackinnon"
    },
    {
      "affiliations": [
        "Medical College of Wisconsin, Milwaukee, WI"
      ],
      "name": "D Lim"
    },
    {
      "affiliations": [
        "Medical College of Wisconsin, Milwaukee, WI"
      ],
      "name": "J Nerva"
    }
  ],
  "title": "E-145 Microsurgical management of a lawton type V superior petrosal sinus fistula with anomalous anterior inferior cerebellar artery supply",
  "uid": "b106a0ab-106f-58ba-8a0e-4e6d7d2f0707"
}