Craniocervical Junction Vertebral Artery Dural Arteriovenous Fistula With Cranial and Spinal Venous Reflux: 2-Dimensional Operative Video
Bibliographic record
Abstract
Dural arteriovenous fistulae at the craniocervical junction are rare. When present together with spinal and cranial venous reflux they can have an aggressive natural history with hemorrhage or progressive myelopathy from venous congestion. In this operative video we demonstrate key steps in the surgical ligation of a dural arteriovenous fistula supplied by meningeal branches of the V4 segment of the vertebral artery. Informed consent was obtained. The patient was positioned prone with chin tucked. Utilizing a midline suboccipital craniotomy and removal of the arch of C1, the vertebral artery was identified at its V4 segment at it transitions from extra to intradural. The video illustrates how a midline approach can be used to access this lesion and a far lateral approach is not required to access the vertebral artery and its dural branches at the craniocervical junction. Division of the denticulate ligaments and mobilization of the spinal accessory nerve allows visualization of the proximal portion of the draining vein. Important anatomy in this region is demonstrated. The critical use of indocyanine green (ICG) dye is demonstrated as the first 2 clip applications were not proximal enough to obliterate the proximal draining vein and persistent early venous reflux was still seen on ICG. The importance of access to and obliteration of the proximal draining vein is shown. An intraoperative ICG and postoperative angiogram demonstrates complete occlusion of the dural arteriovenous fistula. In this case the patient had minor sensory deficits postoperatively which were resolved by 6 wk postoperatively.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.001 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.003 | 0.001 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.003 | 0.003 |
| Insufficient payload (model declined to judge) | 0.004 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".