Coil embolization of vertebro-vertebral arteriovenous fistula: a case report

Vertebro-Vertebral Arteriovenous Fistulae: A Case Series of Endovascular Management at a Single Center

OBJECTIVE

Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at our center.

METHODS

A retrospective review was conducted on 14 patients diagnosed with a VVF who underwent endovascular treatment at Siriraj Hospital from January 2000 to January 2023. The study assessed patient demographics, presentation, fistula location, treatment strategies, endovascular techniques employed, and treatment outcomes.

RESULTS

Among the 14 patients, 11 (78.6%) were female, with an age range from 25 to 79 years (median: 50 years). Spontaneous VVFs were observed in 64.3% of the cases, including three associated with neurofibromatosis type 1 (NF-1). Iatrogenic injury accounted for two cases, and three patients had VVFs resulting from traffic accidents. A pulsatile neck mass and tinnitus, with or without neurological deficits, were common presenting symptoms. Active bleeding was observed in three cases with vascular injury, while unilateral proptosis, congestive heart failure, and incidental findings each presented in one patient. All the VVFs were successfully obliterated without major treatment complications. Parent vessel sacrifice was performed in 85.7% of the cases, while vertebral artery preservation was achieved in the remaining two patients. Embolic materials included detachable balloons, detachable coils, and n-butyl cyanoacrylate (NBCA) glue. All the presenting symptoms showed improvement, and no morbidity or mortality was observed.

CONCLUSIONS

Endovascular embolization is a feasible and effective approach for achieving complete VVF obliteration with safety. Parent artery sacrifice should not be reluctantly performed, particularly when adequate collateral circulation is demonstrated.

Cervical Extradural Arteriovenous Fistula without Intradural Drainage Successfully Treated with Endovascular Treatment Using Both Transvenous and Transarterial Approach: Case Report and Review of Literatures

The classification of spinal extradural arteriovenous fistulas (AVFs) was reported based on a case series treated by microsurgery in 2009 and endovascular interventions in 2011. The present report describes a patient with extradural AVFs at the cervical spine manifesting gradual progressive radiculomyelopathy of bilateral upper extremities. Magnetic resonance imaging (MRI) revealed a mass sign from C1 to C4 at the right ventral side and the spinal cord was deviated to the left and indicated as a flow void sign. Diagnostic angiography revealed an extradural AVFs located at the C1-C4 level that was supplied by bilateral radicular artery from the vertebral artery (VA) and right ascending cervical artery (ACA). The shunting points were recognized multiply at C2/3 and C3/4 levels on the right. The transvenous embolization to the enlarged extradural venous plexus around the shunting points via right hypoglossal canal and the transarterial embolization against multi-feeders of the branch of left radicular artery, right ACA achieved complete occlusion of the lesions. His symptom was gradually recovered, and angiography performed 2 weeks after embolization showed no recurrence. When the arteriovenous shunts in the upper cervical spine were high flow shunts, transvenous approach via the hypoglossal canal might be one option for the treatment of spinal extradural AVFs.

Clinical features and treatment strategy of paraspinal arteriovenous shunt (PAVS): a systematic review with individual participants data meta-analysis

BACKGROUND

Because of the rarity of the disease, paraspinal arteriovenous shunt (PAVS) is not well recognized, and therapeutic options remain controversial. To introduce a rare disease of PAVS and demonstrate its etiology, clinical features, treatment options, and outcomes, we presented a case report and conducted a systematic review and individual participants data (IPD) meta-analysis.

METHODS

Studies regarding on PAVS were integrated and IPD were obtained including patients' demographics, disease etiology, clinical and radiologic features, clinical courses and outcomes. Clinical manifestation and treatment outcomes were reviewed, and comparison analysis (cervical versus thoracolumbar) were performed. Further, logistic regression analyses were conducted to identify the poor prognostic factors (incomplete obliteration).

RESULTS

Fifty-two articles were selected, and 88 patients enrolled. General and location-specific characteristics of PAVSs were identified: '3/4 of the isolated and 1/4 of the associated etiology', 'bruit, thrill, or murmur (cervical) and weakness (thoracolumbar) as common symptoms', '40% multiple feeders', and '22% intradural venous involvement'. Endovascular treatment was usually preferred (75%). Of 88 enrolled patients, 18 patients showed incomplete obliteration (20.5%). In multivariate analysis, 'etiologies of systematic genetic dysplasia (P = 0.031) and trauma (negatively, 0.038)' were significantly associated with incomplete obliteration. The parameters of 'multiple feeders (0.066)' and 'combined approach (negatively, 0.065)' are verified only in univariate analysis.

CONCLUSION

General as well as location-specific characteristics of PAVS is successfully demonstrated. Approximately 20% of the incomplete obliteration is noted, and three potential poor prognostic factors are identified, namely, 'etiology of systematic genetic dysplasia (positive) and trauma (negative)', 'combined approach (negative), and 'multiple feeders'.

Cervical spinal extradural arteriovenous fistula successfully treated using transarterial balloon-assisted coil embolization

We present the case of a patient who developed compressive radiculopathy that was found to be associated with a spinal extradural arteriovenous fistula. The fistula was successfully obliterated with transarteiral balloon-assisted coiling, after which the patient was symptom-free. Although spinal extradural arteriovenous fistula is rare, this pathology should be considered in the differential diagnosis of spinal radiculopathy or myelopathy. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

Spontaneous Vertebral Arteriovenous Fistula Mimicking Brachial Radiculoplexopathy

BACKGROUND

Vertebral arteriovenous fistulas (VAVFs) are uncommon high-flow communications between a vertebral artery and surrounding venous plexus that occur spontaneously or secondary to trauma.

CASE DESCRIPTION

A woman aged 57 years presented with a multiday history of rapidly progressive numbness and weakness in the left C5-C6 dermomyotomes. Her physical examination findings and subsequent electrophysiological testing were suggestive of a brachial radiculoplexopathy. Noninvasive imaging demonstrated venous congestion with multilevel compromise of the left-sided cervical foramina, and subsequent vertebral angiography confirmed a VAVF, which was treated with trapping of the involved vertebral artery segment. Her numbness and weakness progressively improved with concurrent involution of the dilated veins.

CONCLUSIONS

This is a rare case of VAVF manifesting as a brachial radiculoplexopathy. Although rare, VAVF may be considered as a potential cause in patients presenting with similar symptoms.

Massive Intramedullary Hemorrhage After Subarachnoid Hemorrhage in Patient with Vertebrovertebral Arteriovenous Fistula

BACKGROUND

Hemorrhagic presentations are rare in vertebrovertebral arteriovenous fistula (VVAVF). To the best of our knowledge, this is the first report of a patient initially presenting with subarachnoid hemorrhage and progressing to intramedullary hemorrhage.

CASE DESCRIPTION

The authors report on a 59-year-old man with VVAVF who developed massive intramedullary hemorrhage. Twelve months before ictus, the patient presented with subarachnoid hemorrhage. Although we recommended endovascular surgery, the patient refused treatment. Twelve months after the initial attack, the massive intramedullary hemorrhage in cervical spinal cord caused complete spinal cord injury. Emergent endovascular intervention was performed after the intramedullary hemorrhage, but there was no neurologic improvement.

CONCLUSIONS

Identification of this phenomenon is important in VVAVF because intramedullary hemorrhage dramatically degrades patient outcome. Prompt surgical intervention is mandatory for VVAVF cases presenting with subarachnoid hemorrhage.

Vertebral Arteriovenous Fistula: A Review Article

OBJECTIVE

Vertebrovertebral fistulas (VVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities, outcome, and complications associated with treatment.

METHODS

A literature search was performed by a reference librarian and after screening, 128 case reports and 16 case series were left for inclusion in the review. All possible data were abstracted by 3 authors, results were tabulated, and descriptive statistics (mean, range, and proportions) were reported. No formal statistical analysis was performed as part of this study.

RESULTS

A total of 280 patients were analyzed. VVFs can be categorized in 3 subgroups (iatrogenic, spontaneous, and traumatic), based on the mechanism of formation, and these different causes share different underlying demographics that bear important treatment considerations. Traumatic VVFs are more commonly seen in young men; the spontaneous form is more commonly seen in young women. Iatrogenic VVFs are more commonly seen in elderly people. Spontaneous VVFs are most commonly located between C1 and C2. Most iatrogenic (n = 39; 57%), spontaneous (n = 106; 82%), and traumatic (n = 53; 73%) VVFs were treated with deconstructive (defined as occlusion of fistula and feeding vessels) endovascular therapy. Overall treatment-related permanent morbidity was 3.3% (9/270) and mortality was 1.5% (4/270).

CONCLUSIONS

VVFs are uncommon lesions, and treatment is often indicated, even in patients without retrograde venous drainage. When treatment is undertaken, the cause of presentation and associated patient demographics should be considered when planning the treatment strategy.

Endovascular treatment of symptomatic high-flow vertebral arteriovenous fistula as a complication after c1 screw insertion

High-flow vertebral arteriovenous fistulas (VAVF) are rare complications of cervical spine surgery and characterized by iatrogenic direct-communication of the extracranial vertebral artery (VA) to the surrounding venous plexuses. The authors describe two patients with VAVF presenting with ischemic presentation after C1 pedicle screw insertion for a treatment of C2 fracture and nontraumatic atlatoaxial subluxation. The first patient presented with drowsy consciousness with blurred vision. The diffusion MRI showed an acute infarction on bilateral cerebellum and occipital lobes. The second patient presented with pulsatile tinnitus, dysarthria and a subjective weakness and numbness of extremities. In both cases, digital subtraction angiography demonstrated high-flow direct VAVFs adjacent to C1 screws. The VAVF of the second case occurred near the left posterior inferior cerebellar artery originated from the persistent first intersegmental artery of the left VA. Both cases were successfully treated by complete occlusion of the fistulous portion and the involved segment of the left VA using endovascular coil embolization. The authors reviewed the VAVFs after the upper-cervical spine surgery including C1 screw insertion and the feasibility with the attention notes of its endovascular treatment.

A successful hybrid repair for vertebral arteriovenous fistula with extracranial vertebral artery aneurysm

A 40-year-old female presented with general fatigue. Echocardiography and computed tomography revealed a cervical vertebral arteriovenous fistula (VAF) with an extracranial vertebral artery aneurysm (VAA). She had closure of an atrial septal defect via right jugular vein catheterization at 5 years of age. Considering the anatomical location, a hybrid endovascular and surgical procedure was successfully performed to exclude both the VAF and VAA from the arterial circulation. This procedure may be considered an alternative to treat vertebral arterial pathology.

Spinal extradural arteriovenous fistulas

Object

Our understanding of spinal extradural arteriovenous fistulas (eAVFs) is relatively limited. In this study the authors aimed to provide the demographics, natural history, and treatment results of these rare lesions.

Methods

The authors performed a pooled analysis of data in the PubMed database through December 2012. Individualized patient data were extracted to elucidate demographic, clinical, and angioarchitectural features of spinal eAVFs as well as outcomes following different treatment strategies.

Results

Information on 101 patients was extracted from 63 eligible studies. The mean patient age was 45.9 years, and there was no significant overall sex predilection. Only 3% of the lesions were incidental, whereas 10% occurred in patients who had presented with hemorrhage. None of the 64 patients with at least 1 month of untreated follow-up sustained a hemorrhage over a total of 83.8 patient-years. Patients with lumbosacral eAVFs were significantly older (mean age 58.7 years, p < 0.0001), were significantly more often male (70% male, p = 0.02), had significantly worse presenting Aminoff-Logue motor and bladder scores (p = 0.0008 and < 0.0001, respectively), and had the greatest prevalence of lesions with intradural venous drainage (62% of cases, p < 0.0001). Neurofibromatosis Type 1 (30% of cases, p < 0.0001) and subarachnoid hemorrhage (9% of cases, p = 0.06) were associated with and exclusively found in patients with cervical eAVFs. The overall complete obliteration rate was 91%. After a mean follow-up of 1.7 years, the clinical condition was improved in 89% of patients, the same in 9%, and worse in 2%. Obliteration rates and outcome at follow-up did not significantly differ between surgical and endovascular treatment modalities.

Conclusions

Spinal eAVFs are rare lesions with a low risk of hemorrhage; they cause neurological morbidity as a result of mass effect and/or venous hypertension. Their treatment is associated with a high rate of complete obliteration and improvement in preoperative symptoms.

WITHDRAWN: Onyx embolization of high flow spontaneous cervical vertebral arteriovenous fistula

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Onyx embolization of high-flow spontaneous cervical vertebral arteriovenous fistula

BACKGROUND AND IMPORTANCE

High-flow spontaneous vertebral arteriovenous shunts in patients with fibromuscular disease (FMD) are rare. Onyx embolization of the recipient veins with shunt disconnection and preservation of the affected vertebral artery in a patient with FMD has not been reported.

CLINICAL PRESENTATION

A 59-year-old female presented with progressive dizziness, pre-syncopal episodes, and tinnitus. Catheter-based angiography identified features of fibromuscular dysplasia and a high-flow right cervical vertebral artery arteriovenous shunt. Onyx embolization of the principle draining veins was performed with initial detachable coil placement. Complete disconnection of the shunt was achieved without sacrifice of the parent vertebral artery.

CONCLUSION

Spontaneous high-flow vertebral arteriovenous shunts can be successfully occluded with Onyx/detachable coil embolization of the principle recipient veins.

Comparative analysis of spinal extradural arteriovenous fistulas with or without intradural venous drainage: a systematic literature review

Object

Spinal arteriovenous malformations (AVMs) are classified into types according to anatomical characteristics: dural arteriovenous fistulas (AVFs), intramedullary AVMs, perimedullary AVFs, and extradural AVFs. Spinal extradural AVFs are much rarer than other types of spinal AVMs, and the available literature on this clinical entity has been based only on case reports or small case series. To investigate the clinical characteristics of patients with spinal extradural AVFs, the authors systematically reviewed the associated literature in the MRI era.

Methods

The PubMed database was searched for all relevant English-language case reports and case series published from 1990 to 2011. The clinical differences between Type A with and Type B without intradural venous drainage were statistically compared, especially regarding clinical features and angiographic and MRI findings.

Results

Forty-five cases of spinal extradural AVFs were found. Type A spinal extradural AVFs were diagnosed in patients with a significantly older age (mean 63.5 years) as compared with Type B AVFs (mean 34.3 years, p < 0.0001). Most cases of Type A spinal extradural AVFs exhibited a diffuse high signal intensity of the spinal cord on T2-weighted MR images and no mass effect (p < 0.0001), and they commonly occurred in the thoracolumbar and lumbar regions (p < 0.0001). On the other hand, cases of Type B lesions exhibited a normal signal intensity of the cord with severe mass effect due to an enlarged extradural venous plexus, and they commonly occurred in the cervical and upper thoracic regions (p < 0.0001), frequently in patients with neurofibromatosis Type 1 (p = 0.049). Because Type B AVFs consisted of high-flow, multiple complex anastomoses between arteries and the epidural venous plexus, patients with these lesions tended to undergo multisession treatments, and the rate of partial AVF occlusion was significantly higher than for Type A AVFs (p = 0.018), although there was no difference in symptom outcomes between the 2 groups.

Conclusions

To the best of the authors' knowledge, a comparative analysis of the clinical differences in patients with extradural AVFs with or without intradural venous drainage has yet to be described in the literature. They concluded that in the diagnosis of spinal extradural AVF, evaluation of intradural venous drainage is important because the cause of myelopathy determines the treatment goals.

Endovascular treatment of high-flow cervical direct vertebro-vertebral arteriovenous fistula with detachable coils and Onyx liquid embolic agent

We report the first experience in the treatment of high-flow cervical direct vertebro-vertebral arteriovenous fistula (VVAVF), which was successfully occluded with detachable coils and Onyx through transarterial approach. A 20-year-old female presented with 2-month history of paresis of bilateral extremities. Magnetic resonance imaging (MRI) showed that the dilated ventral epidural veins as well as the dilated left paraspinal veins compressed the spinal cord. Digital subtraction angiography demonstrated high-flow VVAVF between the left vertebral artery (VA) and the surrounding venous plexus at the C3 cervical level. The fistulas were also fed by backward flow from the right VA and left ascending cervical arteries. Transarterial endovascular treatment was performed by using detachable coils and Onyx; immediate angiographic obliteration was achieved. VVAVF-related symptoms resolved gradually, and there was complete neurologic recovery without clinical consequences on clinical follow-up. The fistulas remained closed, as ascertained by 2-month follow-up computed tomography angiography and MRI. No new neurological deficit related to the procedure was detected. The endovascular treatment of direct VVAVF with combination of detachable coils and Onyx is feasible, safe, and highly effective with low morbidity and mortality.

Combined transarterial and percutaneous coiling of a spontaneous vertebrovertebral fistula associated with neurofibromatosis Type 1

The authors report a rare case of spontaneous left vertebrovertebral fistula associated with neurofibromatosis Type 1 in a young woman. The patient had undergone previous failed surgical attempts to close the fistula and presented to the authors with recurrence of the fistula and neurological deterioration. Successful obliteration of the fistula with combined transarterial and percutaneous coiling with Guglielmi detachable coils resulted in disappearance of the fistula and significant neurological improvement.

Delayed presentation of a vertebral arterio-venous fistula secondary to penetrating cervical trauma: endovascular management using coil embolisation - a case report

Vertebro-vertebral arteriovenous fistulae occur infrequently. We report on such a case with delayed presentation following penetrating neck injury. This was successfully treated via coil embolisation. A 40-year-old woman presented with a subjective tinnitus that was abolished by turning her head to the right. She had sustained penetrating neck trauma 6 months earlier. Doppler Ultrasound and magnetic resonance angiogram confirmed the presence of a vertebral arterio-venous fistula. Using a trans-femoral arterial approach, the left vertebral artery was embolised by deployment of multiple coils. The patient had no return of symptoms at 3 months follow up. Radiological diagnosis and endovascular management of this condition is discussed.

Traumatic vertebro-vertebral arteriovenous fistula manifesting as radiculopathy. Case report

A 58-year-old man presented with a traumatic vertebro-vertebral arteriovenous fistula (VVAVF) after attempting suicide by thrusting scissors into his right anterior cervical region. Two months later he noticed weakness and numbness of the right upper extremity. Examination revealed bruit in the right neck, no cranial nerve palsy, and weakness of the right deltoid and biceps muscles. Hypalgesia and hypesthesia were noted in the right C5 and C6 dermatomes. Magnetic resonance imaging demonstrated a mass lesion on the right ventral aspect of the spinal canal from C2 to C7. Right vertebral artery angiography showed a pseudoaneurysm of the right vertebral artery and a high-flow arteriovenous fistula between the right vertebral artery and vein. The right vertebral artery was occluded with detachable coils because the fistula showed high blood flow and the right posterior inferior cerebellar artery was well opacified from the left vertebral artery. This procedure resulted in complete obliteration of the arteriovenous fistula. The preoperative motor and sensory symptoms improved. Endovascular treatment by coil embolization was effective in our patient with traumatic VVAVF.

Diagnostic et traitement des fistules vertébrovertébrales

Vertebrovertebral Arteriovenous Fistula (V.V.A.V.F.) is a relatively rare entity. It may be an incidental finding or be detected in patients presenting with pulsatile tinnitus, cervical bruit, or vertebro-basilar insufficiency. It can be spontaneous but it most frequently is post-traumatic in etiology. The authors report 8 patients, 4 women and 4 men aged between 20 to 77 years, with 4 post-traumatic V.V.A.V.F. and 4 spontaneous V.V.A.V.F. that were seen over a 15 year period. Imaging work-up included Doppler US (n=4), MRI 9n=3) and angiography (n=8). Seven of 8 patients were treated successfully using an endovascular technique (5 with balloon occlusion, 1 with coil embolization and 1 using a mechanical maneuver), without complication or recurrence, except in one case. We compare our results with published reports from the literature and review the underlying pathology and management strategies of V.V.A.V.F.

Spinal arteriovenous malformations: new classification and surgical treatment

Object

Spinal vascular malformations represent rare and insufficiently studied pathological entities characterized by considerable variation. Insufficient study of this disease is connected with the complexity of its diagnosis, which restricts the development of surgical treatments that are differentiated according to the type of malformation. Great difficulties are caused by the lack of a clear structural–hemodynamic classification of spinal arteriovenous malformations (AVMs). At present the classification created between 1991 and 1998 by the combined efforts of different authors is the most widely used one. According to this classification, four categories are distinguishable: Type I, dural arteriovenous fistulas (AVFs); Type II, intramedullary glomus AVMs; Type III, juvenile or combined AVMs; and Type IV, intradural perimedullary AVFs. Vascular tumors are also classified, as follows: hemangiomas, hemangioblastomas, angiosarcomas, hemangiopericytomas, angiofibromas, angiolipomas, and hemangioendotheliomas, as well as cavernous malformations.

Methods

In this study the authors analyze the diagnostic data and results of treatment in 91 patients with AVMs and AVFs who were treated at the Institute of Neurosurgery between 1995 and 2005. The patients' ages ranged from 9 to 83 years; the mean age was 42.9 years. For spinal vascular malformations we devised a classification that took into account the aforementioned features of AVMs: the anatomical characteristics of a malformation and its angiostructural and hemodynamic features. In all patients the neuroimaging modalities used in the investigation of their lesions included magnetic resonance (MR) imaging and selective spinal angiography. Three-dimensional computerized tomography angiography studies were obtained in 14 patients, and MR angiography was used in 17.

Conclusions

For successful surgical treatment of spinal AVMs it is necessary to obtain data about their localization, vascular structure, and hemodynamics that are as complete as possible. This information will promote the use of optimum surgical procedures and the latest methods of microsurgical and endovascular interventions, with treatments differentiated according to the type of malformation. One should try to use the least invasive endovascular approach in these cases,where possible, to occlude the AVM or reduce the intensity of blood flow by means of embolization. To perform an AVM resection or occlusion, one should use a direct approach to the malformation, blocking only the vessels supplying blood to the malformation and preserving the vessels feeding the spinal cord.