Neurofibromatosis Type 1-Associated Extracranial Vertebral Artery Aneurysm Complicated by Vertebral Arteriovenous Fistula After Rupture: Case Report and Literature Review

A case of spontaneous direct vertebral artery - External vertebral venous plexus fistula in the upper cervical portion

Background

Spontaneous direct vertebral artery-external vertebral venous plexus (VA-EVVP) fistula is a rare disease that presents in patients with neurofibromatosis type 1 (NF-1) or trauma.

Case Description

An 82-year-old female patient with no neurological deficits or trauma presented to our hospital with right hemianopsia. Head magnetic resonance imaging (MRI) revealed left occipital cerebral infarction and magnetic resonance angiography demonstrated high signal intensity in the left transverse sinus (TS). The attending doctor diagnosed an old infarction on the left occipital lobe and dural arteriovenous fistula (AVF) in the TS. After 3 years after the first diagnosis, her new attending doctor re-checked the MRI and performed digital subtraction angiography (DSA). The DSA examination revealed a single-hole AVF between the vertebral artery and external vertebral plexus at the C2 level, which was diagnosed as upper cervical VA-EVVP. The patient presented with tinnitus due to a high-flow VA-EVVP fistula, so we performed coil embolization of the fistula under general anesthesia using a double-catheter technique and achieved subtotal embolization, which diminished the intracranial reflux. The 6-month follow-up DSA image revealed complete obliteration of the AVF.

Conclusion

We report a rare case of upper cervical VA-EVVP fistula in a patient with no history of trauma and relevant medical conditions. Coil embolization of the fistula was performed using a combination of balloon-assisted and double-catheter techniques. Although the patient showed residual shunt flow after the intervention, follow-up DSA revealed complete obliteration. These findings should provide novel insights for the treatment strategy against VA-EVVP fistula.

Cervical radiculopathy secondary to vertebral artery dissection: clinical features and outcomes

PURPOSE

Cervical radiculopathy due to various mechanical causes is commonly seen, however, cervical vertebral artery dissection (cVAD)-related radiculopathy is very rare with poorly characterized clinical outcomes. Thus, we conducted a systematic review of published literature and reported an institutional case to provide a better illustration of this rare entity.

METHODS

We systematically reviewed the PubMed literature and queried the clinical database at our center for cVAD-related radiculopathy. We described the baseline characteristics of patients with cVAD-related radiculopathy, the involved segment, diagnostic approach and treatment options.

RESULT

14 previously published studies met the inclusion criteria and along with the case we identified in our center, our study included 17 patients total (median age: 35 years, 9 females). C5 was the most commonly affected root and ipsilateral shoulder/arm pain along with shoulder abduction weakness was most common presentation. Antiplatelet or anticoagulant therapy was the treatment of choice. Most cases managed conservatively (82%). Majority of the cases (92%) had either complete or partial resolution of their symptoms.

CONCLUSION

Despite its limitations, this study show that cVAD related radiculopathy is a relatively benign entity with excellent clinical outcomes when managed medically.

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.

Outcomes following surgical and endovascular treatment of extracranial vertebral artery aneurysms (VAA): a systematic evaluation of the literature

Extracranial vertebral artery aneurysms are rare complications resulting from trauma and multiple different diseases. However, the difference between clinical and surgical profiles is well understood. To investigate the clinical and interventional outcomes following extracranial vertebral artery aneurysms (VAA) treatment through a systematic review of the literature to date, an electronic database search for full-text English articles was conducted following PRISMA guidelines. The search yielded results on clinical and surgical outcomes for extracranial VAAs. These results included patient-specific risk factors, indications, and techniques. Our literature search resulted in 561 articles, of which 36 studies were qualified to be included in the analysis. A total of 55 patients with multiple various extracranial VAA incidents were included. The mean age of subjects was 42 years (ranging from 13.0 to 76.0 years), and the majority of patients were males (71%, n =39). Blunt trauma was the most frequent risk factor for extracranial VAA formation (35%, n = 19). The majority of aneurysms (60%) were dissected in nature. The most common form of treatment for extracranial VAAs was the use of a flow diverter (24%, n=13). Overall, five (9%) patients had long-term adverse neurological complications following intervention with 5% (n=3) mortality, 2% (n=1) resulting in unilateral vocal cord paralysis, and 2% (n=1) resulted in a positive Romberg sign. The mortality rate is 15.7% in the surgical group, whereas the endovascular treatment did not result in any mortality. The endovascular approach is a safe and effective treatment of extracranial VAAs due to its relatively low overall complication rate and lack of resulting mortality. This is in contrast to the surgical approach which results in a higher rate of complications, recurrence, and mortality outcomes. An understanding of the factors and clinical outcomes associated with the incidence of extracranial VAAs is essential for the future improvement of patient outcomes.

Direct arteriovenous fistula due to a blister-like aneurysm of the supraclinoid internal carotid artery hijacking its adjacent vein

BACKGROUND

This is the first report of a direct acquired arteriovenous fistula (AVF) between an intracranial aneurysm and its adjacent pial vein.

CASE DESCRIPTION

A 33-year-old male suffered subarachnoid hemorrhage. Computed tomography angiography revealed an aneurysm of the supraclinoid internal carotid artery (ICA). Digital subtraction angiography (DSA) showed that the aneurysm of the supraclinoid ICA was blister-like and that one large vessel crossing the aneurysm provided two draining paths into the bilateral cavernous sinuses and superior sagittal sinus. Microsurgery confirmed the presence of a blister-like aneurysm and proved the vessel crossing and connected to the aneurysm to be a pial vein, resulting in a direct AVF between the aneurysm and its adjacent vein. The blister-like aneurysm together with some of the ICA wall was clipped to reconstruct the ICA and preserve the anterior choroidal artery (AchA). Postoperative DSA showed the following: the blister-like aneurysm had been completely clipped; the ICA was narrow, but the blood flow was sufficient; and the AchA was intact. After discharge, the patient recovered uneventfully without neurological deficits.

CONCLUSIONS

Exceptionally, an intracranial ruptured aneurysm can hijack its adjacent pial vein as its draining path, forming a direct AVF. Microsurgery can be used to confirm the angioarchitecture of the AVF, and clipping is a good treatment choice.

Vertebral arteriovenous fistulae (AVF) and vertebral artery aneurysms in neurofibromatosis type 1: A case report and a systematic review

BACKGROUND

Neurofibromatosis type 1 (NF1) is caused by mutations in the NF1 gene on the long arm of chromosome 17, which affects the skin, nervous system, eyes, and skeleton system. Vertebral arteriovenous fistula (AVF) associated with neurofibromatosis type I (NF-1) is rare.

CASE PRESENTATION

We report a 31-year-old postpartum woman with NF1 with vertebral arteriovenous fistulae (AVFs). She presented to our hospital because of neck pain, intracranial hypotension headache, and right upper limb weakness. She had a family history of NF1. After endovascular intervention, the AVF disappeared. However, a new aneurysm appeared on the right vertebral artery V5 dissection after 6 months of follow-up.

CONCLUSIONS

The presence of NF1 in patients who present with neurologic signs should prompt further angiography. Awareness of the coexistence between NF1 and AVF or aneurysm is crucial to avoiding diagnostic delays. Endovascular occlusion of VV-AVF in NF-1 patients is effective and safe.

Successful Endovascular Trapping for Symptomatic Thrombosed Giant Unruptured Aneurysms of the V1 and V2 Segments of the Vertebral Artery: Case Report and Literature Review

A thrombosed giant aneurysm of the V1 and V2 segments of the vertebral artery (VA) is rare. Therefore, there is controversy regarding its optimal treatment. A case of a symptomatic giant VA aneurysm located in the V1 to V2 segments on the left treated successfully by endovascular trapping of the VA is reported. A 68-year-old woman presented with swelling in the left anterior neck. Computed tomography angiography (CTA) showed a giant aneurysm measuring 47 × 58 × 47 mm³ in the left neck. Ten days after her first visit, she presented with sudden onset of left anterior neck pain. Repeated CTA showed a partial thrombus in the aneurysm. Angiography showed two thrombosed giant aneurysms located in the V1 to V2 segments of the left VA. After endovascular trapping for the aneurysms, the anterior neck pain resolved and the aneurysm gradually shrank. This case demonstrates that endovascular surgery is better than open surgery because it is less invasive. When performing endovascular treatment, trapping will be an alternative strategy for a symptomatic giant thrombotic aneurysm of the V1 and V2 segments of the VA if the patient can tolerate ischemia.

Endovascular treatment of vertebro-vertebral arteriovenous fistula in neurofibromatosis type I: A report of two cases and literature review with a focus on endovascular treatment

Vertebro-Vertebral arteriovenous fistula (VV-AVF) associated with neurofibromatosis Type I (NF-1) is rare. We presented two female NF-1 patients with a diagnosis of VV-AVF treated with endovascular approach. The fistula was completely obliterated with balloon assisted embolization and covered stent separately and VA patency was preserved in both cases. Reviewing the literature with a focus on endovascular treatment, endovascular occlusion of VV-AVF in NF-1 patients is safe and effective. To preserve the parent VA patency and obliterate the fistula simultaneously is challenging generally, but feasible in some cases.

Chronic fusiform extracranial vertebral artery aneurysm with recurrent posterior circulation emboli: Case report and review of the literature

We report a case of a 64-year-old man with a fusiform right extracranial vertebral artery aneurysm, spanning over half the extra-cranial V2 (foraminal) segment, presenting with recurrent multi-focal posterior circulation embolic ischaemic stroke. The patient was treated with endovascular embolisation of the right vertebral artery to prevent further thrombo-embolic events. Distal and proximal occlusion of the aneurysmal vertebral artery was performed with a micro-vascular plug with partial aneurysm sack embolisation to aid thrombosis and reduce the risk of recanalisation. Two months post procedure MR angiography confirmed successful aneurysm occlusion with no post-procedural complication. The patient returned to his normal independent life. Endovascular treatment with vessel sacrifice is an effective treatment with low morbidity and we believe the MVP device to be a efficacious option in the vertebral artery.

Vertebral arteriovenous fistulae in neurofibromatosis type1: a systematic review and meta-analysis

INTRODUCTION

Vertebral Arterio-venous fistulas (VAVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. Among spontaneous cases, it is most commonly found to be associated with Neurofibromatosis type 1 (NF1).

EVIDENCE ACQUISITION

We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities and outcome of VAVFs associated with NF1. A literature search was performed by using databases PubMed Central, Embase, Cochrane Library, and Ovid MEDLINE. Also, the grey area search was done using the "Google Scholar" search engine. On screening of the original full-text English language articles, a total of 48 cases were considered suitable for inclusion in this review.

EVIDENCE ANALYSIS

VAVFs in NF1 commonly present between 3rd and 6th decade of life affecting females 2.4 times more than males. Left-sided fistulae were more common than the right side and most seen in the upper V2 segment of the vertebral artery. Most VAVFs in NF 1 patients were treated with constructive (occlusion of fistula only) endovascular therapy (n =26) with a high success rate. Moreover, Pooled proportion of the outcome data have shown significant difference between the endovascular constructive and destructive procedure.

CONCLUSIONS

The spontaneous VAVF, commonly associated with NF-1, often requires treatment. Awareness of the coexistence between NF1 and VAVF is crucial to avoid diagnostic delays and unnecessary surgical intervention leading to disastrous outcomes. Endovascular treatment is the preferred treatment approach while open surgical treatment is required in some complex fistulae and failure of endovascular techniques.

Case Report: Multi-Orifices Vertebral Arteriovenous Fistula With Severe Scoliosis in Neurofibromatosis Type 1: Might Be a Congenital Disease With Mesodermal Dysplasia

Background: Vertebral arteriovenous fistula (AVF) associated with neurofibromatosis type 1 (NF-1) is a rare condition in the previous reports. However, whether vertebral AVF in NF-1 is congenital or NF-1 disease progression hasn't been clarified. Case Description: We reported a 48-year-old male case of vertebral AVF simultaneously combined with thoracic scoliosis and NF-1. Preoperative CT angiography showed the AVF with multiple orifices located on the vessel wall of the vertebral artery, which was proved during the procedure of endovascular treatment. By occluding the parent vertebral artery, the AVF was finally cured. Further whole-exome sequencing identified a novel germline heterozygous point nonsense mutation, c.G397T(p.E133X), in the NF1(NM_000267) gene exon4. Conclusions: From this patient, we speculate that vertebral AVF associated with NF-1 might be a congenital disease as a manifestation of mesodermal dysplasia.

Neurofibromatosis type 1 with subarachnoid haemorrhage from the left vertebral arteriovenous fistula: case presentation and literature review

We present the case of a 47-year-old woman with neurofibromatosis type 1 (NF1) with subarachnoid haemorrhage (SAH) from the left vertebral arteriovenous fistula, along with a review of previous cases. Our patient had a family history of NF1 and presented to the emergency department with a sudden-onset severe headache and neck pain. CT scan showed SAH. CT angiography revealed a left vertebral arteriovenous fistula and an epidural haematoma. She underwent direct surgery and was discharged without neurologic deficits. To our knowledge, this is the first case of SAH caused by perimedullary drainage of a vertebral arteriovenous fistula associated with NF1. In a literature search, we identified 40 cases of vertebral arteriovenous fistula associated with NF1. The majority of vertebral arteriovenous fistulas occurred on the left side and in women. Patients with vertebral arteriovenous fistula typically experience neck pain, radiculopathy, radiculomyelopathy and bruits.

Endovascular and surgical approaches of iatrogenic vertebrovertebral arteriovenous fistula

Vertebrovertebral arteriovenous fistula is an uncommon vascular disease with no clear management guidelines. It is most commonly caused by iatrogenic injury. We have presented the details of two iatrogenic cases and a review to discuss strategies for endovascular and surgical approaches. From the digital subtraction angiography findings, the vertebrovertebral arteriovenous fistulas were occluded by endovascular coil positioning (patient 1) and surgical ligation of the fistulas (patient 2). Although endovascular approaches are increasing in popularity and considered well-tolerated treatments, open surgical treatment is still reserved for the most complex cases and those not feasible for endovascular treatment.

Fatal Tension Hemothorax Combined With Exanguination: A Rare Complication of Neurofibromatosis

Neurofibromatosis (NF) is a common autosomal dominant disorder that can be subdivided into type 1, type 2, and schwannomatosis. Patients with NF1 typically develop café-au-lait spots, scoliosis, and benign neurofibromas. In addition, NF1 predisposes to vascular complications including stenosis, arterial ectasia, and aneurysms. Here, we report the case of an otherwise healthy 32-year-old man who developed a fatal tension hemothorax due to vertebral artery aneurysm rupture. Based on the available literature, we discuss the presentation, workup, and available therapeutic approaches to this complication of neurofibromatosis.

Left colic artery aneurysm rupture after stent placement for abdominal aortic aneurysm associated with neurofibromatosis type 1

BACKGROUND

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease of the skin and soft tissue. Aneurysms associated with NF1 can occur, but a secondary aneurysm rupture is very rare, with very few cases reported in literature.

CASE PRESENTATION

We describe the case of a 67-year-old female with NF1 who underwent endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) rupture. She developed a type Ib endoleak requiring a redo-EVAR. Eighteen days after her primary operation, she was found to have two new left colic artery aneurysms. She required emergency surgery consisting of a left hemicolectomy and transverse colon colostomy. Pathology showed neurofibromatous changes to the peri-vasculature tissue, consistent with her underlying disease.

CONCLUSIONS

Although rare, secondary aneurysms can occur following AAA repair. Patients with soft tissue connective tissue disorders, like NF1, may be at an increased risk for development of these secondary aneurysms. Endovascular repair appears to be a safe approach for NF1 patients with AAA, but endovascular management can be challenging in the setting of NF1. Surgeons should be ready to convert to open surgery if the patient displays persistent signs of bleeding or structural changes related to connective tissue disorders like NF1.

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.

Supraclavicular area swelling in neurofibromatosis patient

Neurofibromatosis 1 is an autosomal dominant disorder characterized by cafe-au-lait spots, cutaneous neurofibroma, and bony deformities. Vascular abnormality such as stenosis, aneurysm, or rupture associated with neurofibromatosis 1 is rare. Rupture of vertebral artery aneurysm into the thoracic cavity is extremely rare. The outcomes of patients with aneurysmal ruptures are very poor when spontaneous hemothorax occur. A 31-year-old woman presented to the emergency department with left shoulder pain and with both lower chest wall pain and left supraclavicular area swelling. The chest computed tomography scan revealed about 4-cm pseudo-aneurysm probable arising from the left vertebral artery with large hematoma at left supraclavicular area. Neurofibromatosis 1 is generally being regarded as a benign disease but has the potential for serious vascular complications. When aneurysms were ruptured, cervical hematoma, hemothorax, or hypotension was developed. It is potentially a life-threatening condition, so it must require emergent management. Emergency physicians must remember the relation of neurofibromatosis 1 and serious vascular complications and ensure rapid access to rule out vascular lesions, so as to prevent the life-threatening condition.

Endovascular treatment of V3 segment vertebro-vertebral arteriovenous fistula with Willis covered stent: Case report and literature review

A 46-year-old male presented to our hospital suffering from right mastoid pulsatile tinnitus secondary to traffic trauma. Digital subtraction angiography was remarkable for a vertebro-vertebral arteriovenous fistula fed by the right vertebral artery at the C1 level. Dual platelet therapy was administrated before and after the operation, then a Willis covered stent was deployed at the orifice of the fistula. Post-operative angiography showed proper stent localization but some contrast agent leaking from the fistula. Angiography performed 6 months post-operatively demonstrated no leak from the fistula and the patency of the right vertebral artery. This case demonstrated that an intracranial covered stent could be used as an alternative, successful treatment for vertebro-vertebral arteriovenous fistula.

[White hemithorax in a young women carrying coffee and milk spots]

INTRODUCTION

Neurofibromatosis type 1 (NF1) or Von Recklinghausen disease is an autosomal dominant genetic disorder with multivisceral manifestations. We report the case of a spontaneous haemothorax in a young lady wearing this genetic pathology.

CASE REPORT

A 31-year-old woman with kyphoscoliosis developed acute chest pain and dyspnea. The physical examination revealed a right pleuritic syndrome, coffee and milk spots and neurofibromas of the trunk. Biological assessment showed anemia at 6.4g/dl. Chest x-ray revealed a right side opacification. The pleural puncture showed an incoagulable hemorrhagic fluid. The chest CT scan showed no vascular abnormalities. The diagnosis of spontaneous haemothorax, revealing NF1, was retained. Transfusion and thoracic drainage were performed followed by haemostasis surgery. Pleural exploration showed pleural hematoma with regard to the 5th intercostal space. Electrocoagulation and declogging were performed. The evolution of the patient was favorable.

CONCLUSION

Haemothorax is a rare and serious complication which may reveal NF1. It must be suspected when sudden and spontaneous white haemithorax occurs in NF1.

Subarachnoid Hemorrhage from Vertebral Arteriovenous Fistula without Perimedullary Drainage: Rare Stroke Hemorrhagic Event in a Patient of Neurofibromatosis Type 1

Vertebral arteriovenous fistula (VAVF), which can cause subarachnoid hemorrhage (SAH) when having a perimedurally drainage, has been reported as a rare vascular abnormality in patients with neurofibromatosis type 1 (NF-1). In addition, extracranial vertebral aneurysm (EVAn) coexisting with VAVF and NF-1 is considered rare, and further complication with SAH is extremely rare in patients. There is only one reported case of NF-1 complicated with SAH from VAVF with an EVAn. Here, we present a case of a middle-aged patient with NF-1. The VAVF accompanied by an EVAn was detected with an episode of SAH. The VAVF with an EVAn in our case was accompanied with an epidural varix, lacking of perimedullary drainage, which could be a cause for SAH. We speculate the mechanism of SAH from the VAVF with an EVAn lacking of perimedurally drainage, focusing on hemodynamic stress of the VAVF and the tissue fragility related to NF-1.