• Ryo Horiuchi, Kazuya Kanemaru, Hideyuki Yoshioka, Koji Hashimoto, Hiroaki Murayama, Takashi Yagi, Masakazu Ogiwara, and Hiroyuki Kinouchi.
• Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Yamanashi, Japan.
• World Neurosurg. 2020 May 1; 137: 126-129.

BackgroundIntraoperative confirmation of the vascular anatomy and blood flow contributes to the safety of the surgery for perimedullary arteriovenous fistulas (PAVF). However, because the PAVF at the craniocervical junction (CCJ) is mainly located on the ventral spinal cord surface, it is difficult to observe the entire pathology by a conventional surgical approach. To achieve increased viewing angle and visualization of real time blood flow, we introduced endoscope-integrated fluorescein video angiography in the treatment for PAVF at the CCJ for the first time.Case DescriptionA 63-year-old man presented with subarachnoid hemorrhage due to rupture of PAVF at the CCJ, fed by both the right C1 radiculomedullary artery and the anterior spinal artery (ASA). Suboccipital craniotomy and C1 hemilaminotomy was performed and microscopic observation revealed partial anatomy of the PAVF covered by subarachnoid clots on the ventrolateral surface at the right C1 nerve root level. However, pathology ventral to the C1 nerve root was obscure and an endoscope-integrated fluorescein video angiography was introduced, which clearly demonstrated the PAVF components and the ASA.ConclusionsAccording to these findings, the PAVF was coagulated and the ASA was preserved. Endoscope-integrated fluorescein video angiography allowed to visualize its real-time blood flow, leading to a safe and reliable treatment.Copyright © 2020 Elsevier Inc. All rights reserved.

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