Vertebral arteriovenous fistula that developed in the same place as a previous ruptured aneurysm: a case report

Extracranial Thrombosed Vertebral Aneurysm Associated Neurofibromatosis Type1 Treated by Neuroendovascular Coil Embolization: A Case Report and Review of Literature

A 46-year-old NF1 patient with sudden visual disturbance had a thrombotic vertebral artery aneurysm causing cerebral infarction. Endovascular internal trapping was performed successfully, with complete recovery and no neurological deficits. Although this is a rare case, it suggests that endovascular therapy could be successful for vascular lesions complicated by NF1.

Endovascular management of V3 segment vertebro-vertebral fistula: case management and literature review

Vertebro-vertebral fistula involving the V3 segment of the vertebral artery is a rare vascular pathology which is either spontaneous or traumatic in origin. We describe a post-operative traumatic vertebro-vertebral fistula in a 47-year old lady with NF-1. We review reported cases of V3 segment vertebrovertebral fistula for their incidence, aetiology, clinical presentation, treatment and outcomes using an illustrative case. Traumatic V3 segment vertebrovertebral fistula is predominantly managed with parent vessel occlusion. Per the algorithm presented, we suggest endovascular management of non-traumatic fistula be based on the anatomical variance of the contralateral vertebral artery.

Endovascular treatment for V3 segment direct vertebral-venous fistulas: A report of two cases and a literature review

INTRODUCTION AND IMPORTANCE

Direct vertebrovertebral fistulas (VVFs) involving the V3 segment of the vertebral artery (VA) are rare. Endovascular treatment (EVT) can be used to obliterate these VVFs.

CASE PRESENTATION

Case 1 was a 30-year-old male with limb weakness. He had grade V muscle strength in his limbs. Angiography confirmed a low-flow direct VVF of the V3 segment. The right VA was well developed. Coiling of the VVF and its parent VA obliterated the VVF. The vertebrobasilar arteries had sufficient blood from the right VA. Postoperatively, the patient recovered well. Case 2 was a 51-year-old male with headache and weakness of the limbs. He had grade IV muscle strength in his limbs. Angiography revealed a high-flow direct VVF in the V3 segment. The left VA was well developed. Coiling of the VVF and its parent VA obliterated the VVF. The vertebrobasilar arteries had sufficient blood from the left VA. Postoperatively, the patient recovered well.

CLINICAL DISCUSSION

Direct VVF of the V3 segment is difficult to treat, and EVT, including reconstructive and deconstructive approaches, can be an effective treatment option. According to this case report and literature review, reconstructive EVT is ideal; however, it is difficult to perform. Currently, deconstructive EVT may be the mainstream option for treating direct VVF of the V3 segment.

CONCLUSION

In certain cases where the contralateral VA is well developed, coiling the fistula and the parent VA is still an effective treatment.

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.

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.

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.

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'.

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.

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.

Successful endovascular coil embolisation of a ruptured V1-segment vertebral artery dissecting aneurysm making a fistula with the adjacent vein

Sudden supraclavicular pain is often associated with myocardial infarction but seldom due to a rupture of V1-segment vertebral artery aneurysm. A ruptured V1 segment of vertebral artery dissecting aneurysm making a fistula with the adjacent vein has rarely been described in literature. Here we present a case of a 29-year-old healthy woman with sudden supraclavicular pain and palpable mass that developed after pain. Initial ultrasound showed suspicion of large haematoma. CT angiogram showed a left-sided dissecting V1-segment vertebral artery ruptured aneurysm. Angiography showed an additional fistula between the aneurysm and the adjacent vein. The patient was treated successfully with coil embolisation. The vertebral artery occlusion was well tolerated without any complications. Endovascular coiling is a fast and effective treatment modality. However, a parent vessel occlusion can be sometimes dangerous if the contralateral vertebral artery supply is not sufficient. Surgical possibilities to reconstruct the parent vessel should also be considered in complex cases.

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.

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.

The endovascular management of neurofibromatosis-associated aneurysms: A systematic review

BACKGROUND

Neurofibroblastoma (NF) or Von Recklinghausen disease, is an autosomal dominant disorder affecting one in 3000 individuals. Cardinal features of NF include multiple café-au-lait macules, benign neurofibromas, and iris hamartomas. Albeit less common, vascular lesions of medium and large-sized arteries and veins are a well-recognized complication, which can lead to fatal consequences such as rupture.

METHOD

A systematic review was conducted as per the Preferred Reporting Instructions for Systematic Reviews and Meta-analysis (PRISMA) guidelines utilizing PubMed, EMBASE, and Cochrane databases.

RESULTS

There were 59 articles identified involving 66 patients (mean age 44.3 ± 30 years), of which 89% had neurofibromatosis type 1. There were 63.6% of patients who presented with aneurysm rupture, 33.3% presented with intact symptomatic aneurysms, and 3.1% presented with intact asymptomatic aneurysms. Anatomically, 4.5% of patients suffered from intracranial aneurysms; 12.1% suffered from visceral artery aneurysms (including hepatic, superior mesenteric, gastroduodenal and renal arteries), and other patients suffered from aneurysms within the chest, abdomen, pelvis, upper limbs and neck. Amongst the various endovascular procedures, coiling was performed in 83.3% of cases. There were 12 covered stents employed in 10 patients (18.2%), of which 7 were balloon-expandable grafts; 2 were self-expandable graft; 3 were not mentioned. The rates of major and minor complications were 15% and 6% respectively, with 4 cases (6%) of perioperative death. On a mean follow-up of 15 months (range 1.5-72 months), two patients developed a distant vascular lesion from the treated lesion.

CONCLUSION

Endovascular management is safe and effective even in hemodynamically unstable neurofibroblastoma patients at all ages. Vascular tree screening should be conducted in clinically suspicious patients to prevent fatal aneurysmal complications. A formal meta-analysis could not be performed due to the lack of randomized controlled trials.

Treatment Challenges of a Primary Vertebral Artery Aneurysm Causing Recurrent Ischemic Strokes

Background. Extracranial vertebral artery aneurysms are a rare cause of embolic stroke; surgical and endovascular therapy options are debated and long-term complication may occur. Case Report. A 53-year-old man affected by neurofibromatosis type 1 (NF1) came to our attention for recurrent vertebrobasilar embolic strokes, caused by a primary giant, partially thrombosed, fusiform aneurysm of the left extracranial vertebral artery. The aneurysm was treated by endovascular approach through deposition of Guglielmi Detachable Coils in the proximal segment of the left vertebral artery. Six years later the patient presented stroke recurrence. Cerebral angiography and Color Doppler Ultrasound well characterized the unique hemodynamic condition developed over the years responsible for the new embolic event: the aneurysm had been revascularized from its distal portion by reverse blood flow coming from the patent vertebrobasilar axis. A biphasic Doppler signal in the left vertebral artery revealed a peculiar behavior of the blood flow, alternately directed to the aneurysm and backwards to the basilar artery. Surgical ligation of the distal left vertebral artery and excision of the aneurysm were thus performed. Conclusion. This is the first described case of NF1-associated extracranial vertebral artery aneurysm presenting with recurrent embolic stroke. Complete exclusion of the aneurysm from the blood circulation is advisable to achieve full resolution of the embolic source.

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

BACKGROUND

Extracranial vertebral artery aneurysm related to neurofibromatosis type 1 (NF1) is rare. Aneurysmal rupture typically induces such symptoms as cervical hematoma, hemothorax, and hypotension. Here we report a case of ruptured extracranial vertebral artery aneurysm in a patient with NF1 who, rather than cervical hematoma, hemothorax, or hypotension, developed a vertebral arteriovenous fistula (AVF) after aneurysm rupture.

CASE DESCRIPTION

A 35-year-old woman with a family history of NF1 presented with sudden-onset right neck and shoulder pain. Computed tomography angiography showed a right extracranial vertebral artery aneurysm. She had neither a cervical hematoma nor hypotension; however, angiography showed an AVF secondary to aneurysmal rupture. The patient was treated with endovascular coil embolization to prevent re-rupture. Postoperatively, her right neck and shoulder pain improved, and she was discharged without further neurologic deficits.

CONCLUSIONS

This patient's clinical course suggests that if there is minimal bleeding from an NF1-associated ruptured extracranial vertebral artery aneurysm, then typical symptoms, such as cervical hematoma, hemothorax, and hypotension, may be absent. Thus, ruptured extracranial vertebral artery aneurysm should be considered in the differential diagnosis of patients with NF1 with sudden-onset radiculopathy, even in the absence of typical symptoms. The detection of a vertebral AVF provides a useful clue to the diagnosis of aneurysm rupture in such cases.

Endovascular Internal Trapping of Ruptured Occipital Artery Pseudoaneurysm Associated with Occipital-Internal Jugular Vein Fistula in Neurofibromatosis Type 1

Spontaneous cervical extradural pseudoaneurysms or arteriovenous fistulas (AVFs) are rare vascular diseases. We report a case of ruptured occipital artery (OA) pseudoaneurysm associated with occipital-internal jugular vein (IJV) fistula in neurofibromatosis type 1. Endovascular internal trapping via the OA was attempted; however, the distal entry of the OA could not be accessed because of the high shunt flow and tortuosity of the OA. The distal part of the OA was obliterated with coil via a transvenous approach through the IJV and pseudoaneurysm. The proximal entry of the OA was obliterated with coil and glue under proximal flow control with a balloon, and the fistula was successfully obliterated without placement of coils in the pseudoaneurysm. When ordinary internal trapping via a transarterial approach is not possible, the transvenous approach should be considered as an alternative for AVF associated with an aneurysmal component.

Spinal extradural arteriovenous fistulas: clinical article

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.

Ruptured extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. Case report

A 31-year-old man presented with a ruptured right extracranial vertebral artery aneurysm associated with neurofibromatosis type 1, manifesting as acute onset of right neck and shoulder pain, and right supraclavicular mass. Three-dimensional computed tomography angiography showed a large aneurysm involving the right extracranial vertebral artery associated with a pseudoaneurysm. The aneurysm was successfully treated by transarterial endovascular trapping with detachable coils. Extracranial vertebral artery aneurysm is rare, but the mortality of ruptured cases is extremely high, so early diagnosis and early treatment are important. The present case shows that endovascular treatment was very effective.

Vertebral artery aneurysms and cervical arteriovenous fistulae in patients with neurofibromatosis 1

Vascular involvement in the setting of neurofibromatosis type 1(NF1) has been well described. However, the coexistence of NF1 with vertebral artery (VA) aneurysms and arteriovenous fistulae (AVFs) is a rare occurrence. A 60-year-old female with NF1 and other severe comorbidities presented with acute respiratory insufficiency caused by a ruptured large VA aneurysm and an associated AVF that required emergent intubation and eventual repair through endovascular techniques that resolved her symptoms. A detailed description of this case and a comprehensive review of the literature are also presented.

Spinal intraosseous arteriovenous fistula in the fractured vertebral body

A 68-year-old woman presenting with progressive paraparesis was diagnosed with an AVF involving a previously fractured L1 vertebral body on which feeders from multiple segmental arteries converged. The most distinctive feature in our patient was that the fistula was located in the vertebral body. Transarterial embolization of the segmental arteries with coils and glue resulted in total obliteration of the fistula, which in turn resulted in symptom improvement.

Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature

BACKGROUND

Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease. Functional outcome is particularly uncertain for the small group of patients that are unable to stand at the time of diagnosis (grade 5 gait disturbance on the Aminoff-Logue scale, ALS). The objective of this study is to examine the final functional outcome of patients with SDAVF in grade 5 gait ALS before treatment.

METHODS

We conducted a PubMed search using the keyword "spinal dural arteriovenous fistula." A review of the clinical series and single well-detailed case reports of SDAVF gathered 106 patients with grade 5 gait ALS on the initial examination. Additionally, we report the case of a 56-year-old man presenting acute paraplegia and urinary retention on admission who had complained of sporadic motor and sphincter disturbances for 1 year. Spine T2-weighted MR imaging showed a central hyperintensity within the spinal cord, and the angiography demonstrated a T-11 SDAVF. Interruption of the fistula was performed through an urgent one-level laminectomy.

RESULTS

Grade 5 gait ALS was present in 25% of the patients with SDAVF included in the clinical series. Latest follow-up showed that gait disturbance improved in 73% of patients after treatment, although less than 6% became grade 1 gait ALS. Micturition disturbances improved in 39%. Exploration of our patient showed improvement to grade 1 gait ALS 1 year after the surgical treatment.

CONCLUSION

Interruption of SDAVF in paraplegic patients may improve the final functional gait outcome in some cases. No complete recovery (grade 0 gait ALS) was achieved after treatment. Micturition disturbances had a worse prognosis than motor deficits.

Extracranial vertebral artery involvement in neurofibromatosis type I. Report of four cases and literature review

SUMMARY

Neurofibromatosis type 1 (NF-1) is one of the most common inherited diseases and as an autosomal dominant genetic disorder results from NF-1 gene mutation with 100% penetration and wide phenotypic variability. The disease can involve a wide variety of tissues derived from all three embryonic layers. NF-1 vasculopathy has been described primarily in peripheral arteries, but arteries supplying the CNS may also be involved. Of those, extracranial vertebral involvement is the commonest and most important. A series of four patients with NF-1 and vascular disease of the vertebral artery is described with a review of the pathophysiology, vascular phenotypes, their management and the pertinent literature.

Surgical Treatment of Cervical Arteriovenous Fistula in a Patient with Neurofibromatosis Type 1

Vasculopathies are frequently associated with neurofibromatosis type-1, and they are generally occlusive or stenotic type lesions. Vertebral arteriovenous fistula (AVF) is quite rare in neurofibromatosis type 1 patients. They can be treated with surgical excision or endovascular occlusion. We describe a surgically treated cervical AVF in a neurofibromatosis type 1 (NF-1) patient and discuss the selection of the patient for the surgery. Although endovascular occlusion is the first line treatment option for cervical AVFs, some selected cases can be successfully treated by surgery. Surgery should be considered as a treatment option in spite of its risks, especially for cervical AVF which is associated with fibromuscular system diseases like NF-1.

PSEUDOTUMORAL PRESENTATION OF A CERVICAL EXTRACRANIAL VERTEBRAL ARTERY ANEURYSM IN NEUROFIBROMATOSIS TYPE 1

OBJECTIVE

Neurofibromatosis Type 1 (NF1) is known to be associated with vascular lesions. Association with an extracranial vertebral artery aneurysm is very rare. We report the case of such an aneurysm mimicking a cervical neurofibroma in NF1.

CLINICAL PRESENTATION

An 18-year-old woman with previously diagnosed NF1 presented with a C6 radiculopathy. There were no clinical features suggesting a vascular origin for the lesion. The computed tomographic and standard magnetic resonance imaging scans showed a C5–C6 contrast-enhancing lesion responsible for bony erosion. Subsequent, magnetic resonance angiography and digital subtraction angiography diagnosed the lesion as a C5–C6 vertebral artery aneurysm.

INTERVENTION

The lesion was treated by endovascular occlusion of both the aneurysm and the parent vertebral artery with an initial immediate disappearance of the pain.

CONCLUSION

This case serves as a reminder of the importance of ruling out a vertebral artery aneurysm with angiography when managing cervical lesions in patients with NF1.

Vascular abnormalities in patients with neurofibromatosis syndrome type I: clinical spectrum, management, and results

PURPOSE

Neurofibromatosis type I (NF-I) is an autosomal dominant disorder affecting one in 3000 individuals. Vascular abnormalities are a well-recognized manifestation of NF-I. The purpose of this study is to review the spectrum, management, and clinical outcome of patients with vascular abnormalities and NF-I.

METHODS

We retrospectively reviewed 31 patients (15 males, 16 females) with clinical NF-I and vascular abnormalities identified from imaging or operative findings between 1976 and 2005.

RESULTS

The diagnosis of NF-I was made at a mean age of 11 +/- 10 years with vascular lesions identified at a mean age of 38 +/- 16 years. There were 76 vascular abnormalities, including 38 aneurysms, 20 arterial stenoses, 5 arteriovenous malformations (AVM), 5 arteries compressed or invaded by neural tumors, and 6 abnormalities of the heart valves. Arterial lesions were located in the aorta (n = 17) and in the renal (n = 12), mesenteric (n = 12), carotid-vertebral (n = 10), intracerebral (n = 4), and subclavian-axillary and iliofemoral arteries (3 each). Interventions were required in 23 patients (74%); 15 underwent 24 arterial reconstructions, including 9 renal, 8 aortic, 4 mesenteric, 2 carotid, and 1 femoral. The other eight patients had excision of AVM in three, vessel ligation in two, and clipping of cerebral aneurysms, coil embolization of hepatic aneurysms, and left thoracotomy in one patient each. One patient died of ruptured abdominal aortic aneurysm. Six patients (26%) had postoperative complications, including pneumonia in two, and stroke, acalculous cholecystitis, brachial plexopathy and chylothorax in one patient each. The median follow up was 4.1 years (range, 6 months to 20 years). Late vascular problems developed in three patients, including graft stenoses in two and rupture of another aortic aneurysm in one. Freedom from graft-related complications was 83% at 10 years. Patient survival at 10 years was 77%, less than the 86% expected survival for the general population (P < .001).

CONCLUSION

Patients with NF-I have a wide spectrum of vascular abnormalities, most notably aneurysms or stenoses of the aortic, renal, and mesenteric circulation. Operative treatment of symptomatic patients with vascular lesions or large aneurysms is safe, effective, and durable.

Extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. A case report

SUMMARY

Extracranial vertebral artery aneurysm associated with neurofibromatosis (NF1) is very rare. The aneurysm was successfully treated by endovascular trapping of the aneurysm and proximal vertebral artery with coils.

Spontaneous spinal epidural arteriovenous fistulae in neurofibromatosis type-1

BACKGROUND

NF-1 is one of the most common autosomal-dominantly inherited genetic disorders with an incidence of approximately 1:3500. We report a case and review the literature to characterize spontaneous spinal AVF that occur in neurofibromatosis (NF-1).

CASE REPORT

A 51-year-old woman presented with NF-1 and progressive radiculomyelopathy. Angiography revealed an AVF terminating in a giant intraspinal epidural varix extending paraspinally through the C3/4 neural foramen. Trapping of the AVF attempted 18 years earlier prevented endovascular access for embolization, and vigorous bleeding made direct surgical resection impossible. Therefore, as palliation, arterial feeding collaterals were occluded, and surgically exposed tortuous veins were packed with coils. Laminectomies and partial resection of the epidural varix resulted in subtotal occlusion with clinical improvement.

CONCLUSION

The spinal AVF associated with NF-1 appears to show dominant venous drainage to the intraspinal extradural and paraspinal venous plexus without evidence of intradural drainage. The vertebral artery is typically the origin of the fistula. A giant venous varix and numerous collateral feeders to the vertebral artery may give an AVM-like appearance. Clinically, the fistulae produce a syndromic triad including symptoms of NF-1, progressive radiculomyelopathy, and a bruit. Treatment is direct attack on the fistula by either surgery or embolization. If, however, a direct approach cannot be chosen, occlusion of feeding vessels combined with laminectomies can result in long-term symptomatic improvement.

Dural arteriovenous fistula as a late complication of upper cervical spine fracture

✓ The authors report an unusual case of a dural arteriovenous fistula (DAVF) in the cervical spine after a C1–2 fracture. The patient presented with a delayed epidural hematoma and quadriparesis. The DAVF was successfully treated by coil embolization and the patient made a full recovery. The possibility of a DAVF as a late complication of an upper cervical spine fracture should be considered when a patient presents with a spinal epidural hematoma.

Large vertebral arteriovenous fistula treated with stent-grafts--case report

A 24-year-old woman presented with neck bruit and thrill. Neurological examination revealed no focal abnormality. Angiography and magnetic resonance imaging showed an arteriovenous fistula (AVF) at the C4-5 levels of the right vertebral artery (VA). The fistula had a single orifice that drained into the epidural veins via the C4-5 intervertebral foramen. A stent-graft was made of a 3.9 cm balloon-expandable stent and an expandable polytetrafluoroethylene graft sutured outside the stent. The stent-graft was advanced through the femoral artery up to the VA but did not pass far enough distally to seal the entire fistula because of the high friction between the bulky device and the small vessel. Another 2 cm stent-graft was delivered and successfully positioned across the fistula. The AVF completely disappeared and the right VA was well preserved. Follow-up angiography at 3 weeks and 5 months after the treatment showed no fistula and no stenosis inside the stent-grafts. Stent-grafts are useful to treat AVF with a large orifice. The stent-graft is a promising technology to treat neurovascular diseases, although improvement is required for use in smaller vessels.

Diagnosis and endovascular treatment of vertebral arteriovenous fistulas in neurofibromatosis type 1

SUMMARY

We present diagnostic problems, strategies, techniques and material selection for endovascular treatment of high flow arteriovenous fistula (AVF) of tortuous and fragile vertebral artery (VA) with neurofibromatosis type 1 (NF1). Diagnosis of NF1 was easy in four of our cases because of neurofibromatosis, skin pigmentation and various skeletal abnormalities. These stigmas of NF1 were lacking in one case, and the only clue to the diagnosis was ovoid bone defects of the skull vault. Diagnosis was made by performing biopsy of scalp neurofibromas incidentally found on CT. In two initial cases, venous varix were packed with coils by transvenous approach after the transarterial embolisation failed to completely cure the fistula. In three recent cases, blood flow through the fistula was markedly reduced as an initial step by placing detachable coils into the distal and proximal stumps of the afferent VA. Then a liquid adhesive was injected under systemic hypotension to completely occlude the fistula. Control angiography revealed that the AVFs were completely occluded in all cases. Longterm angiographical and clinical status have been stable in all cases. Trying to attain complete occlusion of fistulas using detachable balloons is not an appropriate treatment option for high flow fistulas situated on markedly dilated, tortuous and fragile VAs of patients with NF1. Also, trapping of fistulas is not justified because of the numerous potential feeding pedicles, and makes the following procedure difficult.

Spontaneous vertebral arteriovenous fistula--case report

A 57-year-old male presented with a rare case of spontaneous vertebral arteriovenous fistula manifesting as radiculopathy of the right arm, subsequently associated with pulsating tinnitus and vascular bruit in the nape. He had a past history of chiropractic-induced vertebrobasilar infarction. Angiography showed a simple and direct fistula between the third segment of the right vertebral artery and the epidural veins at the C-1 level, where the artery runs backward above the arch of the C-1 just proximal to the penetration of the dura. The fistula was successfully obliterated by coil embolization, resulting in rapid improvement of the signs and symptoms. Mechanical compression to the nerve roots by the engorged epidural veins with arterial pressure was considered to be the major cause of radiculopathy. Vertebral artery dissection induced by chiropractic manipulation is most likely responsible for the development of the fistula.