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Yasuoka Y, Mitsuhara T, Nabika S, Ohbayashi N, Saito A, Horie N. Lower Cervical Dural Arteriovenous Fistula with a "Skip Lesion" in the Brainstem: A Case Report. NMC Case Rep J 2024; 11:175-179. [PMID: 38966339 PMCID: PMC11223889 DOI: 10.2176/jns-nmc.2024-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/01/2024] [Indexed: 07/06/2024] Open
Abstract
Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular malformations that can occur anywhere in the spine. Most SDAVFs lead to slow aggressive myelopathy due to venous congestion at a level adjacent to the shunt point. However, rare cases of localized brainstem edema without spinal cord lesions have been reported. In this study, we present a case of a lower cervical SDAVF that showed localized congestive edema of the medulla in the absence of an edematous change in the cervical spinal cord. The patient was a 57-year-old woman who experienced vertigo and vomiting without myelopathy that did not improve with conservative treatment. Magnetic resonance imaging (MRI) revealed high signal intensity in the left medulla on T2-weighted imaging (T2WI), while angiography revealed an SDAVF at the right C8 segmental level supplied by the right thyrocervical trunk. She underwent surgical interruption of the draining vein, which led to a rapid improvement in her symptoms. A subsequent follow-up MRI confirmed resolution of both the medullary edema and the dilated draining vein. SDAVFs may cause vertigo and vomiting, which are brainstem symptoms. Early diagnosis and surgical intervention are crucial for successful treatment outcomes.
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Affiliation(s)
- Yuki Yasuoka
- Department of Neurosurgery, Matsue Red Cross Hospital, Matsue, Shimane, Japan
| | - Takafumi Mitsuhara
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan
| | - Shinya Nabika
- Department of Neurosurgery, Matsue Red Cross Hospital, Matsue, Shimane, Japan
| | - Naohiko Ohbayashi
- Department of Neurosurgery, Matsue Red Cross Hospital, Matsue, Shimane, Japan
| | - Asahi Saito
- Department of Neurosurgery, Matsue Red Cross Hospital, Matsue, Shimane, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Hiroshima, Japan
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Tanaka M, Kuge A, Saito R, Sasaki K, Yamaki T, Kondo R, Sonoda Y. Estimation of the rupture point of the craniovertebral junction intradural arteriovenous fistula with vessel wall magnetic resonance image and its pathological findings: A case report. Surg Neurol Int 2024; 15:149. [PMID: 38742004 PMCID: PMC11090560 DOI: 10.25259/sni_163_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024] Open
Abstract
Background Arteriovenous fistulas (AVFs) of the craniocervical junction (CCJ) and intradural AVFs are often associated with aneurysms and varics, and it is sometimes difficult to identify the ruptured point on radiological images. We report a case in which vessel wall magnetic resonance image (VW-MRI) was useful for identifying the ruptured point at the CCJ AVF. Case Description A 70-year-old man presented with a sudden onset of headache. He had Glasgow Coma Scale E4V5M6, world federation of neurosurgical societies (WFNS) Grade I. Fisher group 3 subarachnoid hemorrhage and hydrocephalus were found on head computed tomography. Cerebral angiography showed a spinal AVF at the C1 level of the cervical spine. Magnetic resonance image-enhanced motion sensitized driven equilibrium (MSDE-method showed an enhancing effect in part of the AVF draining vein, but the vascular architecture of this lesion was indeterminate. We performed continuous ventricular drainage for acute hydrocephalus and antihypertensive treatment. Cerebral angiography was performed 30days after the onset of the disease, and was revealed an aneurysmal structure in a portion of the AVF draining vein, which VW-MRI initially enhanced. On the 38th day after onset, he underwent direct surgery to occlude the AV fistula and dissect the aneurysmal structure. Histopathology showed that the aneurysmal structure was varices with lymphocytic infiltration, and hemosiderin deposition was observed near the varices. Conclusion Recently, VW-MRI has been reported to show an association between the enhancement of varices in dural AVF and rupture cases. VW-MRI, especially the enhanced MSDE method, may be useful in estimating the ruptured point in arteriovenous shunt disease.
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Affiliation(s)
- Masahiro Tanaka
- Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Atsushi Kuge
- Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
- Department of Emergency Medicine, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Ryozo Saito
- Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Kosuke Sasaki
- Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Tetsu Yamaki
- Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Rei Kondo
- Stroke Center, Yamagata City Hospital Saiseikan, Yamagata, Japan
| | - Yukihiko Sonoda
- Department of Neurosurgery, Yamagata University Faculty of Medicine, Yamagata, Japan
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Peeters JB, Bojanowski MW. Surgical treatment of marginal sinus dural arteriovenous fistula: a narrative review. Neurochirurgie 2024; 70:101534. [PMID: 38301429 DOI: 10.1016/j.neuchi.2024.101534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Dural arteriovenous fistulas of the marginal sinus (DAVFms) are uncommon and complex, with varied symptoms. Their complexity is heightened by the region's dense anastomotic network, posing risks for endovascular treatment. Surgical intervention can be effective, but this depends on thorough pre-operative understanding and optimal intra-operative visualization of the fistula. OBJECTIVE To review the relevant anatomy, presentation patterns of DAVFms, and provide insights for surgical treatment. METHODS Recent literature on DAVFms was reviewed, and three surgical cases are discussed to highlight treatment principles. RESULTS The symptoms of a DAVFms vary depending on its venous drainage pattern. Drainage may be either ascending towards the cranial compartment or descending towards the spinal canal. Patients suffering from DAVFms may experience hemorrhage, particularly when venous drainage is directed upwards. Congestive symptoms of the spinal cord or brainstem can occur in cases of downward venous drainage. Compared to the endovascular approach, open surgery has a higher success rate in obliterating the fistula and yields better outcomes in cases of perimedullary venous drainage. Achieving surgical success necessitates thorough preoperative evaluation and adequate surgical exposure. Brainstem hyperintensity observed on T2-weighted MRI scans is linked to a poorer prognosis for recovery. CONCLUSION Treating complex DAVFms often requires surgery, as endovascular methods may not be feasible. Successful surgery hinges on a precise understanding of the fistula's venous architecture and its spatial relationships, assessed using digital substraction angiography (DSA), angio-MRI, and angio-CT. Optimal intraoperative exposure is crucial for effective surgery.
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Affiliation(s)
- Jean-Baptiste Peeters
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center, 1000, Rue St-Denis Montréal, QC H2X 0C, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center, 1000, Rue St-Denis Montréal, QC H2X 0C, Canada.
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Lee S, Kubota M, Tajima Y, Kojima I, Higuchi Y. Transarterial embolization of radicular arteriovenous fistula at the craniocervical junction. Radiol Case Rep 2024; 19:1712-1717. [PMID: 38384708 PMCID: PMC10877126 DOI: 10.1016/j.radcr.2024.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/20/2024] [Indexed: 02/23/2024] Open
Abstract
Craniocervical junction arteriovenous fistula (CCJ AVF) is a rare vascular disorder. Direct surgery for CCJ AVF is generally reported to have better outcome compared to endovascular treatment. However, no certain consensus has been obtained so far. We report a case of radicular CCJ AVF treated by transarterial embolization that resulted in a good outcome. A 69-year-old man presented with subarachnoid hemorrhage primarily in the posterior cranial fossa. Based on digital subtraction angiography showed radicular CCJ AVF with varix. Transarterial embolization was performed with n-butyl-2-cyanoacrylate on day 17 after onset and successfully cured. The neurovascular anatomy of CCJ AVF is complicated, but endovascular treatment may be a treatment option with detailed understanding of angioarchitecture and selective endovascular procedure.
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Affiliation(s)
- Songhyon Lee
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
- Department of Neurosurgery, Narita Red Cross Hospital, Chiba, Japan
| | - Masaaki Kubota
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Tajima
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Iori Kojima
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Ma Y, Song Z, Wang Y, Wang J, He C, Li G, Zhang P, Hong T, Sun L, Hu P, Ye M, Zhang H. Clinical features, treatment strategies and outcomes of craniocervical junction arteriovenous fistulas: a cohort study of 193 patients. Stroke Vasc Neurol 2024; 9:18-29. [PMID: 37236656 PMCID: PMC10956106 DOI: 10.1136/svn-2023-002436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are rare. The current treatment strategies for AVFs with different angioarchitecture need to be clarified. The present study aimed to analyse the correlation between angioarchitecture and clinical characteristics, share our experience in treating this disease and identify risk factors associated with subarachnoid haemorrhage (SAH) and poor outcomes. METHODS A total of 198 consecutive patients with CCJ AVFs from our neurosurgical centre were retrospectively reviewed. The patients were grouped according to their clinical manifestations, and their baseline clinical characteristics, angioarchitecture, treatment strategies and outcomes were summarised. RESULTS The patients' median age was 56 years (IQR 47-62 years). The majority of patients were men with 166 (83.8%) patients. The most common clinical manifestation was SAH (52.0%), followed by venous hypertensive myelopathy (VHM) (45.5%). The most common CCJ AVFs type was dural AVF, with 132 (63.5%) fistulas. The most frequent fistula location was C-1 (68.7%) and dural branch of vertebral artery (70.2%) was the most involved arterial feeders for fistulas. The most common direction of venous drainage was descending intradural drainage (40.9%), followed by ascending intradural drainage (36.5%). Microsurgery was the most common treatment strategy applied for 151 (76.3%) patients, 15 (7.6%) patients were treated with interventional embolisation only, and 27 (13.6%) received both interventional embolisation and microsurgical treatment. The learning curve for microsurgery only was analysed by cumulative summation method, and the turning point was the 70th case, and blood loss in post-group was lower than that in pre-group (p=0.034). At the last follow-up, there were 155 (78.3%) patients with favourable outcomes (modified Rankin Scale(mRS)<3). Age≥56 (OR 2.038, 95% CI 1.039 to 3.998, p=0.038), VHM as the clinical manifestation (OR 4.102, 95% CI 2.108 to 7.982, p<0.001) and pretreatment mRS≥3 (OR 3.127, 95% CI 1.617 to 6.047, p<0.001) were significantly associated with poor outcomes. CONCLUSION The arterial feeders and direction of the venous drainage were important factors in the clinical presentations. The location of fistula and drainage vein was essential for choosing different treatment strategies. Older age, VHM onset and poor pretreatment functional status predicted poor outcomes.
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Affiliation(s)
- Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Zihao Song
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yinqing Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jiachen Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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Hashikata H, Goto M, Maki Y, Nishida N, Ando M, Ishibashi R, Toda H, Iwasaki K. Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review. Acta Neurochir (Wien) 2023; 165:3985-3990. [PMID: 37059919 DOI: 10.1007/s00701-023-05578-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/31/2023] [Indexed: 04/16/2023]
Abstract
While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery.
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Affiliation(s)
- Hirokuni Hashikata
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan.
| | - Masanori Goto
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minami, Chuo, Kobe, Hyogo, 650-0047, Japan
| | - Yoshinori Maki
- Department of Neurosurgery, Hikone Chuo Hospital, 421 Nishiima, Hikone, Shiga, 522-0054, Japan
- Department of Rehabilitation, Hikari Hospital, 3-35-1 Saikawa, Otsu, Shiga, 520-0002, Japan
| | - Namiko Nishida
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
| | - Mitsushige Ando
- Department of Neurosurgery, Shiga General Hospital, 5-4-30 Moriyama, Shiga, 524-8524, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
| | - Hiroki Toda
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
| | - Koichi Iwasaki
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
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Su H, Yu J. Treatment of high cervical arteriovenous fistulas in the craniocervical junction region. Front Neurol 2023; 14:1164548. [PMID: 37441609 PMCID: PMC10335834 DOI: 10.3389/fneur.2023.1164548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
The craniocervical junction (CCJ) is a complex region. Rarely, arteriovenous fistulas (AVFs) can occur in the CCJ region. Currently, it is accepted that CCJ AVFs should only refer to AVFs at the C1-C2 levels. It is reasonable to assume that high cervical CCJ AVFs are being referred to when discussing CCJ AVFs. High cervical CCJ AVFs can be divided into the following four types: dural AVF, radicular AVF, epidural AVF and perimedullary AVF. Until now, it was difficult to understand high cervical CCJ AVFs and provide a proper treatment for them. Therefore, an updated review of high cervical CCJ AVFs is necessary. In this review, the following issues are discussed: the definition of high cervical CCJ AVFs, vessel anatomy of the CCJ region, angioarchitecture of high cervical CCJ AVFs, treatment options, prognoses and complications. Based on the review and our experience, we found that the four types of high cervical CCJ AVFs share similar clinical and imaging characteristics. Patients may present with intracranial hemorrhage or congestive myelopathy. Treatment, including open surgery and endovascular treatment (EVT), can be used for symptomatic AVFs. Most high cervical CCJ AVFs can be effectively treated with open surgery. EVT remains challenging due to a high rate of incomplete obliteration and complications, and it can only be performed in superselective AVFs with simple angioarchitecture. Appropriate treatment can lead to a good prognosis.
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Wada K, Tanei T, Hattori K, Hatano H, Fujitani S, Ito R, Kubo H, Nishimura Y, Maesawa S, Saito R. Unique vascular structures of a radicular arteriovenous fistula at the craniocervical junction along the first cervical spinal nerve: A case report. Surg Neurol Int 2023; 14:85. [PMID: 37025516 PMCID: PMC10070252 DOI: 10.25259/sni_122_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/25/2023] [Indexed: 03/12/2023] Open
Abstract
Background:
An arteriovenous fistula (AVF) at the craniocervical junction (CCJ) is a rare vascular malformation. Definitive diagnosis and curative treatment of CCJ AVF are challenging.
Case Description:
A 77-year-old man presented with subarachnoid hemorrhage. Cerebral angiography showed an AVF at the CCJ, which drained into a radicular vein. The lesion was fed by a vertebral artery, anterior and lateral spinal arteries (LSAs), and the occipital artery (OA). There were two unique structures: the LSA originating from the posterior inferior cerebellar artery of the extracranial V3 segment and the OA feeding the shunt. Curative treatment involved two steps: endovascular embolization of feeders using Onyx and surgical shunt disconnection. Feeding arteries were blackened by Onyx, which helped identify the location of the shunt. The shunt was located behind the first cervical (C1) spinal nerve, and the draining vein was confirmed on the deep side of the nerve. A clip was applied to the draining vein distal to the shunt. Tiny vessels supplying the shunt were then coagulated referring to blackened arteries.
Conclusion:
A radicular AVF at the CCJ along the C1 spinal nerve had unique vascular structures. Definitive diagnosis and curative treatment were achieved by combining endovascular embolization using Onyx and direct surgery.
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Affiliation(s)
- Kentaro Wada
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenichi Hattori
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hisashi Hatano
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Shigeru Fujitani
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Risa Ito
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hiroaki Kubo
- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Yusuke Nishimura
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Maesawa
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Congestive myelopathy due to craniocervical junction arteriovenous fistulas mimicking transverse myelitis: a multicenter study on 27 cases. J Neurol 2023; 270:1745-1753. [PMID: 36534201 DOI: 10.1007/s00415-022-11536-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The purpose was to clarify diagnostic clues and pitfalls in cranio-cervical junction arteriovenous fistulas (CCJ AVFs) with congestive myelopathy. METHODS In a multicenter observational study by the Neurospinal Society of Japan, we described the demographics, clinical courses, imaging findings, and outcomes of consecutive patients with CCJ AVFs presenting with congestive myelopathy between 2009 and 2019. RESULTS Twenty-seven patients were included (mean age, 70 years; male, 96%). Progressive symptoms within one day to one month were more common (63%) than chronic symptoms. Myelopathic symptoms were characterized by ascending paralysis beginning from the legs, involving the trunk and arms, and sometimes ending in the brainstem. Fifteen patients (56%) received a misdiagnosis, including acute transverse myelitis. The most common MRI findings were venous congestive edema of the cervical cord (96%) and the brainstem (63%) and surrounding vascular flow voids (100%). The mean extension of congestive edema was 5.5 ± 2.9 vertebral segments. The most common angiographic findings were a dural AVF (78%) at the C1 level (81%) with descending venous drainage (85%). Seven patients (26%) were administered steroids, which resulted in neurological decline in 3. Neurosurgical obliteration of the AVF led to improvements in MRI findings in 75% and a functional status in 67%; however, 44% remained dependent. CONCLUSIONS The myelopathy of CCJ AVFs was characterized by acute ascending paralysis in elderly men. A misdiagnosis was common because of the acute presentation due to a longitudinally extensive spinal cord lesion. Dilated vessels on MRI were a key finding for the correct diagnosis. What is already known on this topic? Slowly progressive myelopathy is a well-known symptom that results from impaired spinal venous drainage due to thoracolumbar AVFs. Although cranio-cervical junction arteriovenous fistulas (CCJ AVFs) constitute a treatable cause of congestive myelopathy, detailed information is not currently available due to their rarity. What does this study add? CCJ AVFs often presented with acute ascending myelopathy in elderly men due to a longitudinally extending cervical cord lesion with surrounding flow voids. Steroid pulse therapy was not effective or even harmful to congestive myelopathy, while neurosurgical treatment effectively obliterated AVFs. How might this study affect research, practice or policy? The results obtained revealed diagnostic clues and pitfalls from the largest dataset of patients with CCJ AVFs in a multicenter cohort.
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Sato S, Fujita S, Hiramoto Y, Hayashi M, Kushida N, Hirai N, Nakayama H, Saito N, Ito K, Sakurai T, Iwabuchi S. A case of subarachnoid hemorrhage due to perimedullary arteriovenous fistula with multiple feeders at the craniocervical junction cured by treating the common draining vein. BRAIN HEMORRHAGES 2023. [DOI: 10.1016/j.hest.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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Song Z, Ma Y, Wang Y, He C, Li G, Zhang P, Hong T, Sun L, Hu P, Ye M, Zhang H. Arteriovenous fistulas in the craniocervical junction region: With vs. without spinal arterial feeders. Front Surg 2023; 9:1076549. [PMID: 36684281 PMCID: PMC9852723 DOI: 10.3389/fsurg.2022.1076549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/21/2022] [Indexed: 01/09/2023] Open
Abstract
Objective Arteriovenous fistulas (AVFs) in the craniocervical junction (CCJ) region are a rare occurrence with special clinical manifestations. This study retrospectively reviewed patients with CCJ AVFs treated at our neurosurgical center, aiming to enhance the understanding of CCJ AVFs. Methods A total of 113 patients with CCJ AVFs treated at our neurosurgical center between January 2013 and December 2020 were enrolled. They were grouped as patients with CCJ AVFs with spinal arterial feeders (n = 20) and patients with CCJ AVF without spinal arterial feeders (n = 93). Clinical presentation, angiographic characteristics, intraoperative findings, and treatment outcomes were analyzed. Results The patients' median age was 55 years (IQR 47.5-62 years). The proportion of males in the group without spinal arterial feeders was significantly higher (p = 0.001). Subarachnoid hemorrhage (SAH) was the most common clinical presentation, especially in the group with spinal arterial feeders (p < 0.001). There were significant differences in AVF type, fistula location, and direction of the venous drainage between the two groups (p < 0.001). Intervention embolization combined with microsurgery was more common in treating AVFs with spinal arterial feeders (p = 0.006). Spinal arterial feeders did not affect the outcome (p = 0.275). Conclusions SAH was the most common presentation of CCJ AVFs in this study. Microsurgery and interventional embolization were optional treatment strategies. The angioarchitecture of CCJ AVFs was essential for selecting treatment strategies.
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Affiliation(s)
- Zihao Song
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yinqing Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China,Correspondence: Hongqi Zhang Ming Ye
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China,China International Neuroscience Institute (China-INI), Beijing, China,Correspondence: Hongqi Zhang Ming Ye
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Iampreechakul P, Wangtanaphat K, Wattanasen Y, Hangsapruek S, Lertbutsayanukul P, Siriwimonmas S. Dural arteriovenous fistula of the craniocervical junction along the first cervical nerve: A single-center experience and review of the literature. Clin Neurol Neurosurg 2022; 224:107548. [PMID: 36470044 DOI: 10.1016/j.clineuro.2022.107548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/19/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVFs) of the craniocervical junction (CCJ) are relative rare lesions. Most studies of DAVFs of the CCJ included the fistulas at the foramen magnum, first cervical (C1), and second cervical (C2) level. DAVFs of the CCJ along C1 spinal nerve are rare vascular lesions with distinctive features. Our aim is to review cases of DAVFs of the CCJ along C1 spinal nerve at our institution. METHODS From June 2008 and December 2021. We reviewed a consecutive series of intracranial and spinal DAVFs at our institution and collected all patients harboring DAVFs of the CCJ along C1 spinal nerve. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, treatment methods, and neurological outcome and complications after treatment. All image studies, including cranial computed tomography (CT) scan, cervical magnetic resonance imaging, CT angiography, and digital subtraction angiography (DSA) with rotational CT angiography were analyzed by experienced neuroradiologists. The authors also review of the literature of DAVFs of the C1 spinal nerve. RESULTS The authors identified 7 patients, including 5 men (71.4 %) and 2 women (28.6 %) with median age 54 years, range 48-72 years. Subarachnoid hemorrhage (SAH) occurred in 5 (71.4 %) patients, and progressive myelopathy in 2 (28.6 %). All fistulas except one received blood supply from the radiculomeningeal branch of the VA at C1 level. Venous aneurysms, being the source of bleeding, were detected in all fistulas with SAH. All patients except one were treated by surgical management. One fistula was treated by balloon-assisted Onyx embolization. Most patients had good neurological outcome following surgery. Complete obliteration of all fistulas treated by surgery was confirmed by follow-up DSA obtained 1 week after surgery. Two patients developed temporary pain and spasm of the trapezius muscle after the surgery. One patient resulted in poor neurological outcome and died due to sepsis and acute upper gastrointestinal bleeding one month after failed embolization. For patients with SAH, only one patient required ventriculoperitoneal shunt. CONCLUSIONS DAVFs of the CCJ along the first spinal nerve are rare and a unique subtype of DAVFs at the CCJ. These fistulas account for 1.74 % of all intracranial and spinal DAVFs in the present study. SAH is the major manifestation of DAVFs at C1 spinal nerve that may be overlooked on routine initial DSA. Rotational CT angiography is useful for clarification of the angioarchitecture of these fistulas, including small feeding artery and venous varix. Surgical treatment by interruption of the intradural draining vein should be the treatment of choice for C1 spinal nerve DAVF.
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Affiliation(s)
| | | | - Yodkhwan Wattanasen
- Department of Neurosurgery, Neurological Institute of Thailand, Bangkok, Thailand.
| | - Sunisa Hangsapruek
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok, Thailand.
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13
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Hiramatsu M, Sugiu K, Yasuhara T, Hishikawa T, Haruma J, Nishi K, Yamaoka Y, Ebisudani Y, Edaki H, Kimura R, Date I. Angioarchitecture of the Normal Lateral Spinal Artery and Craniocervical Junction Arteriovenous Fistula Using Contrast-enhanced Cone-beam CT. Clin Neuroradiol 2022; 33:375-382. [PMID: 36219219 DOI: 10.1007/s00062-022-01218-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/08/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE The lateral spinal artery (LSA) perfuses the dorsolateral part of the spinal cord at the craniocervical junction (CCJ). We analyzed the angioarchitecture of the normal LSA and CCJ arteriovenous fistula (AVF). METHODS The first study included 26 patients with a cerebral aneurysm of the posterior circulation. Using slab maximum intensity projection (MIP) images from three-dimensional rotational angiography (3D-RA) and contrast-enhanced cone-beam CT (CE-CBCT), we analyzed the origin of the LSA, its anastomosis with the posterior inferior cerebellar artery (PICA), the point where it reaches the spinal cord, and the visualized range. In the second study, we analyzed the angioarchitecture and treatment results of 7 CCJAVF lesions treated in our department between 2016 and 2021. RESULTS We visualized the normal LSA for all patients. In 23 patients with an intradural origin PICA, all LSAs originated from the C1 or C2 radicular artery, and 8 patients had an anastomosis with the PICA. In three patients with a C1 level origin PICA, all LSAs originated from the PICA. All LSAs reached the dorsolateral part of the spinal cord. The mean visualized range of the LSA was 27.4 mm. The LSA was involved in five of seven CCJAVF lesions (71%). There was one lesion with a spinal infarction after LSA embolization. Other lesions were treated by direct interruption of the AVF, and the ASA and LSA were preserved. CONCLUSION This is the first report that visualized the LSA's normal anatomy using slab MIP images from 3D-RA and CE-CBCT. Knowledge of LSA anatomy is critical to avoid complications during the treatment of CCJAVF.
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Affiliation(s)
- Masafumi Hiramatsu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan.
| | - Kenji Sugiu
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Takao Yasuhara
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Tomohito Hishikawa
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Jun Haruma
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Kazuhiko Nishi
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Yoko Yamaoka
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Yuki Ebisudani
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Hisanori Edaki
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Ryu Kimura
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, 700-8558, Okayama, Japan
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14
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Luo M, He M, Wu C. Perimedullary arteriovenous fistula at craniocervical region secondary to spinal dural arteriovenous fistula at foramen magnum. Asian J Surg 2022; 46:1617-1618. [PMID: 36207211 DOI: 10.1016/j.asjsur.2022.09.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mingtao Luo
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Min He
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Cong Wu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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15
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Song Z, Ma Y, Hong T, Zhang H. Arteriovenous Fistulas Fed by Spinal Arterial Feeders at the Craniocervical Junction Region. Oper Neurosurg (Hagerstown) 2022; 23:472-481. [DOI: 10.1227/ons.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/14/2022] [Indexed: 11/06/2022] Open
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16
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Shiozaki E, Morofuji Y, Kutsuna F, Uchida D, Kawahara I, Ono T, Haraguchi W, Tsutsumi K. Subarachnoid hemorrhage due to a craniocervical junction arteriovenous fistula associated with thrombus formation in the internal jugular vein: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22278. [PMID: 36593679 PMCID: PMC9514286 DOI: 10.3171/case22278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND A craniocervical junction arteriovenous fistula (CCJAVF) is a rare vascular malformation, and its etiology remains unclear. Here, to the best of the authors' knowledge, they present the first case of CCJAVF associated with thrombus formation in the ipsilateral internal jugular vein. OBSERVATIONS An 80-year-old man presented with a sudden occipital headache. Computed tomography revealed a subarachnoid hemorrhage surrounding the brainstem and upper cervical cord. Digital subtraction angiography showed a CCJAVF fed by the left C2 radiculomeningeal artery with ascending intracranial drainage and epidural plexus. After endovascular treatment, the authors retrospectively found that his ipsilateral internal jugular vein and innominate vein were occluded with a huge thrombus at admission. LESSONS This case suggested a restricted antegrade venous flow due to thrombus-induced progressive retrograde intracranial drainage causing hemorrhage. Venous hypertension should be considered one of the causes of hemorrhage due to CCJAVF as well as intracranial arteriovenous fistulas.
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Affiliation(s)
| | | | - Fumiya Kutsuna
- Neurology, Nagasaki Medical Center, Kubara Omura-city, Nagasaki, Japan
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17
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Singh R, Bocanegra-Becerra JE, Turcotte EL, Melita NT, Bendok BR. Commentary: Far Lateral Approach With Intraoperative Indocyanine Green Angiography for Craniocervical Arteriovenous Fistula Obliteration: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e203-e204. [PMID: 35972117 DOI: 10.1227/ons.0000000000000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Rohin Singh
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Jhon E Bocanegra-Becerra
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Evelyn L Turcotte
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Nicolae Teodor Melita
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA.,Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA.,Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA.,Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
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18
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Takai K, Endo T, Seki T, Inoue T, Koyanagi I, Mitsuhara T. Neurosurgical versus endovascular treatment of craniocervical junction arteriovenous fistulas: a multicenter cohort study of 97 patients. J Neurosurg 2022; 137:373-380. [PMID: 34972078 DOI: 10.3171/2021.10.jns212205] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are treated using neurosurgical or endovascular options; however, there is still no consensus on the safest and most effective treatment. The present study compared the treatment results of neurosurgical and endovascular procedures for CCJ AVFs, specifically regarding retreatment, complications, and outcomes. METHODS This was a multicenter cohort study authorized by the Neurospinal Society of Japan. Data on consecutive patients with CCJ AVFs who underwent neurosurgical or endovascular treatment between 2009 and 2019 at 29 centers were analyzed. The primary endpoint was the retreatment rate by procedure. Secondary endpoints were the overall complication rate, the ischemic complication rate, the mortality rate, posttreatment changes in the neurological status, independent risk factors for retreatment, and poor outcomes. RESULTS Ninety-seven patients underwent neurosurgical (78 patients) or endovascular (19 patients) treatment. Retreatment rates were 2.6% (2/78 patients) in the neurosurgery group and 63% (12/19 patients) in the endovascular group (p < 0.001). Overall complication rates were 22% and 42% in the neurosurgery and endovascular groups, respectively (p = 0.084). Ischemic complication rates were 7.7% and 26% in the neurosurgery and endovascular groups, respectively (p = 0.037). Ischemic complications included 8 spinal infarctions, 2 brainstem infarctions, and 1 cerebellar infarction, which resulted in permanent neurological deficits. Mortality rates were 2.6% and 0% in the neurosurgery and endovascular groups, respectively (p > 0.99). Two patients died of systemic complications. The percentages of patients with improved modified Rankin Scale (mRS) scores were 60% and 37% in the neurosurgery and endovascular groups, respectively, with a median follow-up of 23 months (p = 0.043). Multivariate analysis identified endovascular treatment as an independent risk factor associated with retreatment (OR 54, 95% CI 9.9-300; p < 0.001). Independent risk factors associated with poor outcomes (a postoperative mRS score of 3 or greater) were a pretreatment mRS score of 3 or greater (OR 13, 95% CI 2.7-62; p = 0.001) and complications (OR 5.8; 95% CI 1.3-26; p = 0.020). CONCLUSIONS Neurosurgical treatment was more effective and safer than endovascular treatment for patients with CCJ AVFs because of lower retreatment and ischemic complication rates and better outcomes.
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Affiliation(s)
- Keisuke Takai
- 1Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Toshiki Endo
- 2Department of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Miyagi, Japan
- 3Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Toshitaka Seki
- 4Department of Neurosurgery, Hokkaido University, Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Tomoo Inoue
- 2Department of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Miyagi, Japan
- 3Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi, Japan
| | - Izumi Koyanagi
- 5Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Hokkaido, Japan; and
| | - Takafumi Mitsuhara
- 6Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
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19
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Shimada K, Yamaguchi I, Miyamoto T, Sogabe S, Miyake K, Kanematsu Y, Takagi Y. Efficacy of intraarterial indocyanine green videoangiography in surgery for arteriovenous fistula at the craniocervical junction in a hybrid operating room: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE22100. [PMID: 35733826 PMCID: PMC9204929 DOI: 10.3171/case22100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Sufficient understanding of the angioarchitecture of an arteriovenous fistula (AVF) at the craniocervical junction (CCJ) is crucial to surgical treatment but is often difficult because of the complex vascular anatomy. Intraarterial indocyanine green (ICG) videoangiography has emerged as a more useful option for understanding the vascular anatomy than intravenous ICG videoangiography. This report describes two cases of CCJ AVFs successfully treated by surgery using intraarterial ICG videoangiography and describes the efficacy of this technique.
OBSERVATIONS
Case 1 involved a 71-year-old man presenting with tetraparesis after sudden onset of severe headache due to subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) demonstrated CCJ epidural AVF. Intraarterial ICG videoangiography revealed the drainer, which had been difficult to identify. The AVF disappeared after disconnection of the drainer. Case 2 involved a 68-year-old man presenting with severe headache due to SAH. DSA showed multiple AVFs at the CCJ and cerebellar tentorium. Intraarterial ICG videoangiography demonstrated concomitant perimedullary AVF and dural AVF at the CCJ. All AVFs disappeared postoperatively.
LESSONS
Intraarterial ICG videoangiography was useful for definitive diagnosis of CCJ AVF, facilitating identification of feeders and drainers with bright and high phase contrast and allowing repeated testing to confirm flow direction.
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Affiliation(s)
- Kenji Shimada
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Izumi Yamaguchi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Shu Sogabe
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Kazuhisa Miyake
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | | | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
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20
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Takai K, Endo T, Seki T, Inoue T, Koyanagi I, Mitsuhara T. Ischemic complications in the neurosurgical and endovascular treatments of craniocervical junction arteriovenous fistulas: a multicenter study. J Neurosurg 2022; 137:1776-1785. [PMID: 35535831 DOI: 10.3171/2022.3.jns22341] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE A recent comparative analysis between neurosurgical and endovascular treatments for craniocervical junction (CCJ) arteriovenous fistulas (AVFs) revealed better treatment outcomes in the neurosurgery group than in the endovascular group. This finding was attributed to the higher than expected rate of ischemic complications in the endovascular group than in the neurosurgery group (26% vs 7.7%, p = 0.037). The aim of the present study was to describe ischemic complications associated with treatments for CCJ AVFs. METHODS This descriptive study was authorized by the Neurospinal Society of Japan. Data from 97 consecutive patients with CCJ AVFs who underwent neurosurgical (n = 78) or endovascular (n = 19) treatment between 2009 and 2019 were collected from 29 centers. The primary endpoints were details on ischemic complications and their risk factors. Secondary endpoints were details on other complications. RESULTS Among all major complications, ischemic complications were the most common (11% of 97 patients), followed by hemorrhagic complications (7.2%), hydrocephalus (2.1%), and CSF leakage (2.1%). Ischemic complications included 8 spinal, 2 brainstem, and 1 cerebellar infarctions. Iatrogenic occlusion of the anterior or posterior spinal artery from the radiculomedullary or radiculopial arteries caused these complications. Ischemic complications resulted in neurological deficits, including motor paresis, sensory disturbances, and brainstem dysfunction. The modified Rankin Scale score was 3 or higher in 36% of patients with ischemic complications at the final follow-up of 23 months. Risk factors associated with ischemic complications were endovascular treatment (OR 4.3, 95% CI 1.1-16) and spinal feeding arteries (OR 3.8, 95% CI 1.03-14). Most of the other complications were addressed by additional treatment without permanent neurological deficits. CONCLUSIONS Among ischemic complications associated with treatments for CCJ AVFs, spinal infarctions were the most common and were mostly attributed to endovascular procedures for CCJ AVFs fed by spinal arteries. These results support the use of neurosurgery as the first-line treatment for CCJ AVFs.
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Affiliation(s)
- Keisuke Takai
- 1Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo
| | - Toshiki Endo
- 2Department of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Miyagi.,3Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi
| | - Toshitaka Seki
- 4Department of Neurosurgery, Hokkaido University, Graduate School of Medicine, Sapporo
| | - Tomoo Inoue
- 2Department of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Miyagi.,3Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi
| | - Izumi Koyanagi
- 5Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo; and
| | - Takafumi Mitsuhara
- 6Department of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan
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21
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Hiramatsu M, Ishibashi R, Suzuki E, Miyazaki Y, Murai S, Takai H, Takasugi Y, Yamaoka Y, Nishi K, Takahashi Y, Haruma J, Hishikawa T, Yasuhara T, Chin M, Matsubara S, Uno M, Tokunaga K, Sugiu K, Date I. Incidence and clinical characteristics of spinal arteriovenous shunts: hospital-based surveillance in Okayama, Japan. J Neurosurg Spine 2021; 36:670-677. [PMID: 34715647 DOI: 10.3171/2021.7.spine21233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There have been no accurate surveillance data regarding the incidence rate of spinal arteriovenous shunts (SAVSs). Here, the authors investigate the epidemiology and clinical characteristics of SAVSs. METHODS The authors conducted multicenter hospital-based surveillance as an inventory survey at 8 core hospitals in Okayama Prefecture between April 1, 2009, and March 31, 2019. Consecutive patients who lived in Okayama and were diagnosed with SAVSs on angiographic studies were enrolled. The clinical characteristics and the incidence rates of each form of SAVS and the differences between SAVSs at different spinal levels were analyzed. RESULTS The authors identified a total of 45 patients with SAVSs, including 2 cases of spinal arteriovenous malformation, 5 cases of perimedullary arteriovenous fistula (AVF), 31 cases of spinal dural AVF (SDAVF), and 7 cases of spinal epidural AVF (SEAVF). The crude incidence rate was 0.234 per 100,000 person-years for all SAVSs including those at the craniocervical junction (CCJ) level. The incidence rate of SDAVF and SEAVF combined increased with advancing age in men only. In a comparative analysis between upper and lower spinal SDAVF/SEAVF, hemorrhage occurred in 7/14 cases (50%) at the CCJ/cervical level and in 0/24 cases (0%) at the thoracolumbar level (p = 0.0003). Venous congestion appeared in 1/14 cases (7%) at the CCJ/cervical level and in 23/24 cases (96%) at the thoracolumbar level (p < 0.0001). CONCLUSIONS The authors reported detailed incidence rates of SAVSs in Japan. There were some differences in clinical characteristics of SAVSs in the upper spinal levels and those in the lower spinal levels.
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Affiliation(s)
- Masafumi Hiramatsu
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Ryota Ishibashi
- 2Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki
| | - Etsuji Suzuki
- 3Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Yuko Miyazaki
- 4Department of Neurosurgery, Kawasaki Medical School, Kurashiki; and
| | - Satoshi Murai
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Hiroki Takai
- 4Department of Neurosurgery, Kawasaki Medical School, Kurashiki; and
| | - Yuji Takasugi
- 5Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Japan
| | - Yoko Yamaoka
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Kazuhiko Nishi
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Yu Takahashi
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Jun Haruma
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Tomohito Hishikawa
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Takao Yasuhara
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Masaki Chin
- 2Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki
| | - Shunji Matsubara
- 4Department of Neurosurgery, Kawasaki Medical School, Kurashiki; and
| | - Masaaki Uno
- 4Department of Neurosurgery, Kawasaki Medical School, Kurashiki; and
| | - Koji Tokunaga
- 5Department of Neurosurgery, Okayama City Hospital, Okayama City General Medical Center, Okayama, Japan
| | - Kenji Sugiu
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
| | - Isao Date
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama
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22
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Matsubara S, Toi H, Takai H, Miyazaki Y, Kinoshita K, Sunada Y, Yamada S, Tao Y, Enomoto N, Minami YO, Hirai S, Yagi K, Nakashima H, Uno M. Variations and management for patients with craniocervical junction arteriovenous fistulas: Comparison of dural, radicular, and epidural arteriovenous fistulas. Surg Neurol Int 2021; 12:411. [PMID: 34513175 PMCID: PMC8422467 DOI: 10.25259/sni_557_2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/15/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Craniocervical junction arteriovenous fistulas (CCJAVFs) are known to be rare, but variations and clinical behaviors remain controversial. Methods: A total of 11 CCJAVF patients (M: F=9:2, age 54–77 years) were investigated. Based on the radiological and intraoperative findings, they were categorized into three types: dural AVF (DAVF), radicular AVF (RAVF), and epidural AVF (EDAVF). Results: There were four symptomatic patients (subarachnoid hemorrhage in two, myelopathy in one, and tinnitus in one) and seven asymptomatic patients in whom coincidental CCJAVFs were discovered on imaging studies for other vascular diseases (arteriovenous malformation in one, intracranial DAVF in two, ruptured cerebral aneurysm in two, and carotid artery stenosis in two). Of these 11 patients, 2 (18.2%) had multiple CCJAVFs. Of 14 lesions, the diagnoses were DAVF in 5, RAVF in 3, and EDAVF in 6 (C1–C2 level ratio =5:0, 2:1, 3:3). Patients with DAVF/RAVF in four lesions with intradural venous reflux underwent surgery, although an RAVF remained in one lesion after embolization/radiation. Since all six EDAVFs, two DAVFs, and one RAVF had neither feeder aneurysms nor significant symptoms, no treatment was provided; of these nine lesions, one DAVF and one RAVF remained unchanged, whereas six EDAVFs showed spontaneous obliteration within a year. Unfortunately, however, one DAVF bled before elective surgery. Conclusion: CCJAVFs have many variations of shunting site, angioarchitecture, and multiplicity, and they were frequently associated with coincidental vascular lesions. For symptomatic DAVF/RAVF lesions with intradural drainage, surgery is preferred, whereas asymptomatic EDAVFs without dangerous drainage may obliterate during their natural course.
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Affiliation(s)
- Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroyuki Toi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yuko Miyazaki
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Keita Kinoshita
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshihiro Sunada
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Shodai Yamada
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshifumi Tao
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Noriya Enomoto
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | | | - Satoshi Hirai
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
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Spinal vascular malformations: Angiographic evaluation and endovascular management. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:267-304. [PMID: 33272400 DOI: 10.1016/b978-0-444-64034-5.00013-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Spinal vascular malformations (SVM) are classified based on their location (intramedullary, perimedullary, radicular, extradural) and flow pattern (high-flow, low-flow, no arteriovenous shunt). High-flow SVMs are generally congenital lesions diagnosed in children and young patients without gender predominance. They present with hemodynamic disturbances, mass effect, or hemorrhages, but may also be discovered incidentally. Low-flow SVMs tend to be acquired lesions presenting in older men with progressive myelopathy caused by spinal venous hypertension. They are rarely associated with vascular syndromes but may accompany prothrombotic conditions. The sensitivity and specificity of conventional MRI are excellent for high-flow SVMs but poor for low-flow lesions, which are frequently diagnosed with extensive delays reducing the potential for favorable outcomes. The sensitivity of advanced MRI techniques remains unclear, notably for the detection of low-flow shunts without flow voids on conventional MRI. Catheter angiography remains the gold standard modality for the evaluation of the spinal vasculature and its disorders. SVMs can be treated by surgical or endovascular means. Initially plagued by high recurrence rates due to inadequate embolization material, endovascular techniques represent nowadays a valid alternative to surgery, thanks notably to the introduction of liquid embolic agents.
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Umana GE, Scalia G, Chaurasia B, Fricia M, Passanisi M, Graziano F, Nicoletti GF, Cicero S. Perimedullary arteriovenous fistulas of the craniovertebral junction: A systematic review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:157-162. [PMID: 33100763 PMCID: PMC7546045 DOI: 10.4103/jcvjs.jcvjs_106_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/22/2020] [Indexed: 11/22/2022] Open
Abstract
Perimedullary arteriovenous fistulas (PMAVFs) are uncommon vascular malformations, and they rarely occur at the level of the craniovertebral junction (CVJ). The therapeutic management is challenging and can include observation alone, endovascular occlusion, or surgical exclusion, depending on both patient and malformation characteristics. A systematic literature search was conducted using MEDLINE, Scopus, and Google Scholar databases, searching for the following combined MeSH terms: (perimedullary arteriovenous fistula OR dural arteriovenous shunt) AND (craniocervical junction OR craniovertebral junction). We also present an emblematic case of PMAVF at the level of the craniovertebral junction associated to a venous pseudoaneurysm. A total of 31 published studies were identified; 10 were rejected from our review because they did not match our inclusion criteria. Our case was not included in the systematic review. We selected 21 studies for this systematic review with a total of 58 patients, including 20 females (34.5%) and 38 males (65.5%), with a female/male ratio of 1:1.9. Thirty-nine out of 58 patients underwent surgical treatment (67.2%), 15 out of 58 patients were treated with endovascular approach (25.8%), 3 out of 58 patients underwent combined treatment (5.2%), and only 1 patient was managed conservatively (1.7%). An improved outcome was reported in 94.8% of cases (55 out of 58 patients), whereas 3 out of 58 patients (5.2%) were moderately disabled after surgery and endovascular treatment. In literature, hemorrhagic presentation is reported as the most common onset (subarachnoid hemorrhage in 63% and intramedullary hemorrhage in 10%), frequently caused either by venous dilation, due to an ascending drainage pathway into an intracranial vein, or by the higher venous flow rates that can be associated with intracranial drainage. Hiramatsu and Sato stated that arterial feeders from the anterior spinal artery (ASA) and aneurysmal dilations are associated with hemorrhagic presentation. In agreement with the classification by Hiramatsu, we defined the PMAVF of the CVJ as a vascular lesion fed by the radiculomeningeal arteries from the vertebral artery and the spinal pial arteries from the ASA and/or lateral spinal artery. Considering the anatomical characteristics, we referred to our patient as affected by PMAVF, even if it was difficult to precisely localize the arteriovenous shunts because of the complex angioarchitecture of the fine feeding arteries and draining veins, but we presumed that the shunt was located in the point of major difference in vessel size between the feeding arteries and draining veins. PMAVFs of CVJ are rare pathologies of challenging management. The best diagnostic workup and treatment are still controversial: more studies are needed to compare different therapeutic strategies concerning both long-term occlusion rates and outcomes.
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Affiliation(s)
- Giuseppe Emmanuele Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
| | - Bipin Chaurasia
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Marco Fricia
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Maurizio Passanisi
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Francesca Graziano
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
- Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, University Hospital "Policlinico P. Giaccone", Palermo, Italy
| | | | - Salvatore Cicero
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
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Brinjikji W, Colombo E, Lanzino G. Clinical and angioarchitectural characteristics of spinal vascular malformations of the cervical spine. J Neurosurg Spine 2020; 32:755-762. [PMID: 31952038 DOI: 10.3171/2019.11.spine19798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vascular malformations of the cervical spine are exceedingly rare. To date there have been no large case series describing the clinical presentation and angioarchitectural characteristics of cervical spine vascular malformations. The authors report their institutional case series on cervical spine vascular malformations diagnosed and treated at their institution. METHODS The authors retrospectively reviewed all patients with spinal vascular malformations from their institution from January 2001 to December 2018. Patients with vascular malformations of the cervical spine were included. Lesions were characterized by their angioarchitectural characteristics by an interventional neuroradiologist and endovascular neurosurgeon. Data were collected on clinical presentation, imaging findings, treatment outcomes, and long-term follow-up. Descriptive statistics are reported. RESULTS Of a total of 213 patients with spinal vascular malformations, 27 (12.7%) had vascular malformations in the cervical spine. The mean patient age was 46.1 ± 21.9 years and 16 (59.3%) were male. The most common presentations were lower-extremity weakness (13 patients, 48.1%), tetraparesis (8 patients, 29.6%), and lower-extremity sensory dysfunction (7 patients, 25.9%). Nine patients (33.3%) presented with hemorrhage. Fifteen patients (55.6%) had modified Rankin Scale scores of 0-2 at the time of diagnosis. Regarding angioarchitectural characteristics, 8 patients (29.6%) had intramedullary arteriovenous malformations (AVMs), 5 (18.5%) had epidural arteriovenous fistulas (AVFs), 4 (14.8%) had paraspinal fistulas, 4 (14.8%) had mixed epidural/intradural fistulas, 3 (11.1%) had perimedullary AVMs, 2 (7.4%) had dural fistulas, and 1 patient (3.7%) had a perimedullary AVF. CONCLUSIONS This retrospective study of 27 patients with cervical spine vascular malformations is the largest series to date on these lesions. The authors found substantial angioarchitectural heterogeneity with the most common types being intramedullary AVMs followed by epidural AVFs, paraspinal fistulas, and mixed intradural/extradural fistulas. Angioarchitecture dictated the clinical presentation as intradural shunts were more likely to present with hemorrhage and acute onset myelopathy, while dural and extradural shunts presented as either incidental lesions or gradually progressive congestive myelopathy.
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Affiliation(s)
- Waleed Brinjikji
- Departments of1Neurosurgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Giuseppe Lanzino
- Departments of1Neurosurgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
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26
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Hedjoudje A, Peng X, Gautam A, Pardo CA, Sciubba D, Gailloud P. Case of Cowden Syndrome with 15 Spinal Arteriovenous Fistulas. World Neurosurg 2020; 139:567-576. [PMID: 32344142 DOI: 10.1016/j.wneu.2020.04.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spinal vascular malformations are rarely multiple: fewer than 50 observations have been documented so far, with a maximum of 4 coexisting lesions per patient, always restricted to a single vertebral region (e.g., cervical or thoracic). CASE DESCRIPTION We describe the case of a 61-year-old woman with Cowden syndrome with 15 spinal arteriovenous fistulas (AVFs) at the cervical, thoracic, and lumbar levels and an adrenal AVF. She was initially referred for reevaluation of an upper cervical spinal epidural spinal arteriovenous fistula diagnosed 6 years earlier. Her history included breast carcinoma, a malignant salivary gland tumor, and removal of multiple ovarian, thyroid, and gastric hamartomas. Computed tomography and magnetic resonance imaging confirmed the presence of a prominent cervical vascular lesion. Spinal digital subtraction angiography revealed the presence of 15 additional vascular anomalies. CONCLUSIONS This multiplicity of AVFs appears to result from a combination of various factors including local regional hemodynamic changes, growth factor-mediated alterations involving notably vascular endothelial growth factor pathways, and the prothrombotic state associated with abnormalities in blood vessel structure.
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Affiliation(s)
- Abderrahmane Hedjoudje
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
| | - Xiao Peng
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ayushi Gautam
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Sciubba
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Yoshida K, Sato S, Inoue T, Ryu B, Shima S, Mochizuki T, Kuwamoto K, Okada Y, Niimi Y. Transvenous embolization for craniocervical junction epidural arteriovenous fistula with a pial feeder aneurysm. Interv Neuroradiol 2020; 26:170-177. [PMID: 31488023 PMCID: PMC7507230 DOI: 10.1177/1591019919874571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/09/2019] [Indexed: 11/16/2022] Open
Abstract
Arteriovenous fistulas at the craniocervical junction are rare vascular malformations with frequent hemorrhagic presentations, which may have a concurrent pial feeder aneurysm. A 65-year-old man presented with subarachnoid hemorrhage and angiography showed an epidural arteriovenous fistula at the C-2 level with an anterior spinal feeder aneurysm without perimedullary venous drainage. Transarterial coil embolization of the ruptured aneurysm and partial Onyx embolization of the shunt led to thrombosis of the aneurysm. However, three years later angiography showed an increased shunt flow and recurrence of the aneurysm. Transvenous embolization of the shunt using coils and Onyx yielded complete obliteration of the shunt, thus leading to occlusion of the aneurysm. This case demonstrates that partial transarterial embolization of arteriovenous fistula leaves a risk of rebleeding, whereas complete obliteration of the shunt with a transvenous approach can lead to disappearance of the flow-related aneurysm without embolization of the aneurysm itself.
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Affiliation(s)
- Keisuke Yoshida
- Department of Neuroendovascular Therapy, St. Lukes International Hospital, Tokyo, Japan
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Lukes International Hospital, Tokyo, Japan
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Bikei Ryu
- Department of Neuroendovascular Therapy, St. Lukes International Hospital, Tokyo, Japan
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Shogo Shima
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Kentaro Kuwamoto
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, St. Lukes International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Lukes International Hospital, Tokyo, Japan
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Shimizu K, Takeda M, Mitsuhara T, Tanaka S, Nagano Y, Yamahata H, Kurisu K, Yamaguchi S. Asymptomatic spinal dural arteriovenous fistula: case series and systematic review. J Neurosurg Spine 2019; 31:733-741. [PMID: 31323622 DOI: 10.3171/2019.5.spine181513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 05/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal dural arteriovenous fistulas (SDAVFs) commonly present with symptoms of myelopathy due to venous congestion in the spinal cord; asymptomatic SDAVFs are rarely encountered. To elucidate the clinical characteristics of asymptomatic SDAVFs, the authors present 5 new cases of asymptomatic SDAVF and report the results of their systematical review of the associated literature. METHODS Five databases were systematically searched for all relevant English-language articles on SDAVFs published from 1990 to 2018. The clinical features and imaging findings of asymptomatic SDAVFs were collected and compared with those of symptomatic SDAVFs. RESULTS Twenty cases, including the 5 cases from the authors' experience, were found. Asymptomatic SDAVFs were more prevalent in the cervical region (35.0%); cervical lesions account for only 2% of all symptomatic SDAVFs. The affected perimedullary veins tended to drain more cranially (50.0%) than caudally (10.0%). Four cases of asymptomatic SDAVF became symptomatic, 1 case spontaneously disappeared, and the remaining 15 cases were unchanged or surgically treated. CONCLUSIONS The higher prevalence of asymptomatic SDAVFs in the cervical spine might be a distinct feature of asymptomatic SDAVFs. Given that venous congestion is the pathophysiology of a symptomatic SDAVF, abundant collateral venous pathways and unique flow dynamics of the CSF in the cervical spine might prevent asymptomatic cervical SDAVFs from becoming symptomatic. In cases in which venous congestion is avoidable, not all asymptomatic SDAVFs will become symptomatic.
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Affiliation(s)
- Kiyoharu Shimizu
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Masaaki Takeda
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Takafumi Mitsuhara
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Shunichi Tanaka
- 2Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; and
| | - Yushi Nagano
- 2Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; and
| | - Hitoshi Yamahata
- 2Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan; and
| | - Kaoru Kurisu
- 1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima
| | - Satoshi Yamaguchi
- 3Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Mansour A, Endo T, Inoue T, Sato K, Endo H, Fujimura M, Tominaga T. Clipping of an anterior spinal artery aneurysm using an endoscopic fluorescence imaging system for craniocervical junction epidural arteriovenous fistula: technical note. J Neurosurg Spine 2019; 31:279-284. [PMID: 31026820 DOI: 10.3171/2019.1.spine18983] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/29/2019] [Indexed: 01/12/2023]
Abstract
The authors report the case of a 78-year-old man with a craniocervical junction epidural arteriovenous fistula who presented with subarachnoid hemorrhage from a ruptured anterior spinal artery (ASA) aneurysm. Because endovascular embolization was difficult, a posterolateral approach was chosen and a novel endoscopic fluorescence imaging system was utilized to clip the aneurysm. The fluorescence imaging system provided clear and magnified views of the ventral spinal cord simultaneously with the endoscope-integrated indocyanine green videoangiography, which helped safely obliterate the ASA aneurysm. With the aid of this novel imaging system, surgeons can appreciate and manipulate complex vascular pathologies of the ventral spinal cord through a posterolateral approach, even when the lesion is closely related to the ASA.
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Affiliation(s)
- Ahmed Mansour
- 1Department of Neurosurgery, Tohoku University Graduate School of Medicine
- 4Department of Neurosurgery, Menoufia University Graduate School of Medicine, Menoufia, Egypt
| | - Toshiki Endo
- 1Department of Neurosurgery, Tohoku University Graduate School of Medicine
- 2Department of Neurosurgery, Kohnan Hospital
| | - Tomoo Inoue
- 1Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Kenichi Sato
- 3Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan; and
| | - Hidenori Endo
- 1Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | | | - Teiji Tominaga
- 1Department of Neurosurgery, Tohoku University Graduate School of Medicine
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Fujimoto S, Takai K, Nakatomi H, Kin T, Saito N. Three-dimensional angioarchitecture and microsurgical treatment of arteriovenous fistulas at the craniocervical junction. J Clin Neurosci 2018; 53:140-146. [PMID: 29731281 DOI: 10.1016/j.jocn.2018.04.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/23/2018] [Indexed: 10/17/2022]
Abstract
Digital subtraction angiography (DSA) is the gold standard for diagnosing vascular malformations; however, difficulties are associated with visualizing the angioarchitecture of arteriovenous fistulas at the craniocervical junction (CCJ AVFs) using DSA because of their complex regional neurovascular anatomy. The present study evaluated the application of 3-dimensional computer graphics (3D CG) to the surgical planning of CCJ AVFs. Six patients with CCJ AVFs who underwent microsurgery and/or endovascular treatment were included. The results of DSA and 3D CG were compared in the last 3 patients. The visibility of important anatomical structures were evaluated using visibility grading scores. Clinical outcomes were assessed based on the rate of occlusion of AVFs, surgical complications, neurological status, and recurrence in long-term follow-ups. The 3D CG images could combine arteries, veins, the spinal cord and dura mater in one single picture to evaluate the anatomy of CCJ AVFs. The image interpretation of vascular structures, particularly narrow arterial feeders, was significantly better using 3D CG than DSA (overall visibility scores, 97% vs 51%, p = 0.001). In all patients, the complete occlusion of AVFs was achieved by microsurgery except for 2 patients without surgical planning with 3D CG. Postoperatively, the neurological status of all patients improved or stabilized without the recurrence of AVFs (median, 5.4 years). 3D CG may help to improve the quality of the microsurgical procedures in complex AVFs. However, it should be used as a complementary diagnostic modality rather than the alternative of DSA because 3D CG has no hemodynamic information at this time.
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Affiliation(s)
- So Fujimoto
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo 183-8524, Japan.
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Taichi Kin
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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31
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Ma Y, Chen S, Peng C, Wang C, Li G, He C, Ye M, Hong T, Bian L, Liu J, Wang Z, Qureshi AI, Ling F, Zhang H. Clinical outcomes and prognostic factors in patients with spinal dural arteriovenous fistulas : a prospective cohort study in two Chinese centres. BMJ Open 2018; 8:e019800. [PMID: 29331977 PMCID: PMC5781161 DOI: 10.1136/bmjopen-2017-019800] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The short-term outcomes and prognostic factors of patients with spinal dural arteriovenous fistulas (SDAVFs) have not been defined in large cohorts. OBJECTIVE To define the short-term clinical outcomes and prognostic factors in patients with SDAVFs. METHODS A prospective cohort of 112 patients with SDAVFs were included consecutively in this study. The patients were serially evaluated with the modified Aminoff and Logue's Scale (mALS) one day before surgery and at 3 months, 6 months and 12 months after treatment. Univariate and multivariate analyses were performed to identify demographic, clinical and procedural factors related to favourable outcome. RESULTS A total of 94 patients (mean age 53.5 years, 78 were men) met the criteria and are included in the final analyses. Duration of symptom ranged from 0.5 to 66 months (average time period of 12.7 months). The location of SDAVFs was as follows: 31.6% above T7 level, 48.4% between T7 and T12 level (including T7 and T12) and 20.0% below T12 level. A total of 81 patients (86.2%) underwent neurosurgical treatment, 10 patients (10.6%) underwent endovascular treatment, and 3 patients (3.2%) underwent neurosurgical treatment after unsuccessful embolisation. A total of 78 patients demonstrated an improvement in mALS score of one point or greater at 12 months. Preoperative mALS score was associated with clinical improvement after adjusting for age, gender, duration of symptoms, location of fistula and treatment modality using unconditional logistic regression analysis (p<0.05). CONCLUSION Approximately four fifths of the patients experienced clinical improvement at 12 months and preoperative mALS was the strongest predictor of clinical improvement in the cohort.
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Affiliation(s)
- Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Sichang Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Chao Peng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Chunxiu Wang
- Department of Evidence-based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Jiang Liu
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Zhichao Wang
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | | | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute, Beijing, China
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Do ASM, Kapurch J, Kumar R, Port J, Miller JW, Van Gompel JJ. The Long and Winding Road: Thoracic Myelopathy Associated With Occipitocervical Dural Arteriovenous Fistula. World Neurosurg 2017; 108:998.e7-998.e16. [DOI: 10.1016/j.wneu.2017.09.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
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Hiramatsu M, Sugiu K, Ishiguro T, Kiyosue H, Sato K, Takai K, Niimi Y, Matsumaru Y. Angioarchitecture of arteriovenous fistulas at the craniocervical junction: a multicenter cohort study of 54 patients. J Neurosurg 2017; 128:1839-1849. [PMID: 28862546 DOI: 10.3171/2017.3.jns163048] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this retrospective multicenter cohort study was to assess the details of the angioarchitecture of arteriovenous fistulas (AVFs) at the craniocervical junction (CCJ) and to determine the associations between the angiographic characteristics and the clinical presentations and outcomes. METHODS The authors analyzed angiographic and clinical data for patients with CCJ AVFs from 20 participating centers that are members of the Japanese Society for Neuroendovascular Therapy (JSNET). Angiographic findings (feeding artery, location of AV shunt, draining vein) and patient data (age, sex, presentation, treatment modality, outcome) were tabulated and stratified based on the angiographic types of the lesions, as diagnosed by a member of the CCJ AVF study group, which consisted of a panel of 6 neurointerventionalists and 1 spine neurosurgeon. RESULTS The study included 54 patients (median age 65 years, interquartile range 61-75 years) with a total of 59 lesions. Five angiographic types were found among the 59 lesions: Type 1, dural AVF (22 [37%] of 59); Type 2, radicular AVF (17 [29%] of 59); Type 3, epidural AVF (EDAVF) with pial feeders (8 [14%] of 59); Type 4, EDAVF (6 [10%] of 59); and Type 5, perimedullary AVF (6 [10%] of 59). In almost all lesions (98%), AV shunts were fed by radiculomeningeal arteries from the vertebral artery that drained into intradural or epidural veins through AV shunts on the dura mater, on the spinal nerves, in the epidural space, or on the spinal cord. In more than half of the lesions (63%), the AV shunts were also fed by a spinal pial artery from the anterior spinal artery (ASA) and/or the lateral spinal artery. The data also showed that the angiographic characteristics associated with hemorrhagic presentations-the most common presentation of the lesions (73%)-were the inclusion of the ASA as a feeder, the presence of aneurysmal dilatation on the feeder, and CCJ AVF Type 2 (radicular AVF). Treatment outcomes differed among the angiographic types of the lesions. CONCLUSIONS Craniocervical junction AVFs commonly present with hemorrhage and are frequently fed by both radiculomeningeal and spinal pial arteries. The AV shunt develops along the C-1 or C-2 nerve roots and can be located on the spinal cord, on the spinal nerves, and/or on the inner or outer surface of the dura mater.
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Affiliation(s)
- Masafumi Hiramatsu
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
| | - Kenji Sugiu
- 1Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
| | - Tomoya Ishiguro
- 2Department of Neuro-Intervention, Osaka City General Hospital, Osaka
| | - Hiro Kiyosue
- 3Department of Radiology, Oita University Faculty of Medicine, Oita
| | - Kenichi Sato
- 4Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai
| | - Keisuke Takai
- 5Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital
| | - Yasunari Niimi
- 6Department of Neuroendovascular Therapy, St. Luke's International Hospital; and
| | - Yuji Matsumaru
- 7Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
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Tubbs RS, Demerdash A, Loukas M, Curé J, Oskouian RJ, Ansari S, Cohen-Gadol AA. Intracranial Connections of the Vertebral Venous Plexus: Anatomical Study with Application to Neurosurgical and Endovascular Procedures at the Craniocervical Junction. Oper Neurosurg (Hagerstown) 2017; 14:51-57. [DOI: 10.1093/ons/opx080] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 03/15/2017] [Indexed: 01/30/2023] Open
Abstract
Abstract
BACKGROUND
Descriptions of intracranial extensions of vertebral venous plexuses are lacking.
OBJECTIVE
To identify vertebral venous plexuses at the craniocervical junction in cadavers and describe them.
METHODS
The authors dissected 15 ink-injected, formalin-fixed, adult cadaveric heads and measured cranial extensions of the spinal venous plexuses.
RESULTS
All specimens had vertebral venous plexuses at the craniocervical junction composed of multiple interwoven vessels concentrated anteriorly (anterior vertebral plexuses), posteriorly (posterior vertebral venous plexuses), and laterally (lateral vertebral venous plexuses). Veins making up the plexus tended to be largest for the anterior internal vertebral venous plexus. On 33%, a previously unnamed lateral internal vertebral venous plexus was identified that connected to the lateral marginal sinus. The anterior external vertebral venous plexus connected to the basilar venous plexus via transclival emissary veins in 13%; remaining veins connected either intracranially via small perforating branches through the anterior atlanto-occipital membrane (33%) or had no direct gross connections inside the cranium (53%). The anterior internal vertebral plexus, which traveled between layers of the posterior longitudinal ligament, connected to the anterior half of the marginal sinus in 33% and anterolateral parts of the marginal sinus in 20%. The posterior internal venous plexus connected to the posterior aspect of the marginal sinus on 80% and into the occipital sinus in 13.3%. The posterior external venous plexus connected to veins of the hypoglossal canal in 20% and into the posterior aspect of the marginal sinus in 13.3%.
CONCLUSION
Knowledge of these connections is useful to neurosurgeons and interventional radiologists.
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Affiliation(s)
| | - Amin Demerdash
- Pediatric Neurosurgery, Children's of Alabama, Birmingham, Al-abama
| | - Marios Loukas
- Department of Anatomical Sci-ences, St. George's University, Grand Anse, Grenada
| | - Joel Curé
- Department of Neuro-radiology, University of Alabama, Birm-ingham, Alabama
| | | | - Shaheryar Ansari
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana
| | - Aaron A Cohen-Gadol
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana
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Ito A, Endo T, Inoue T, Endo H, Sato K, Tominaga T. Use of Indocyanine Green Fluorescence Endoscopy to Treat Concurrent Perimedullary and Dural Arteriovenous Fistulas in the Cervical Spine. World Neurosurg 2017; 101:814.e1-814.e6. [PMID: 28315801 DOI: 10.1016/j.wneu.2017.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 03/05/2017] [Accepted: 03/07/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Intraoperative microscopic fluorescence angiography using indocyanine green (ICG) provides visual information on real-time blood flow. However, this method cannot be applied for lesions that are not visible under microscopic imaging because excitation light does not reach the targeted vascular structures. Endoscope-integrated ICG video-angiography has recently been advocated to compensate for this limitation. This is the first reported case of a spinal arteriovenous malformation in which endoscope-integrated ICG video-angiography was successfully used. CASE DESCRIPTION We report the case of a 63-year-old man who presented with a subarachnoid hemorrhage from a spinal arteriovenous malformation at the C3 level. We chose the direct surgery option with a posterior approach to treat this lesion. Although the preoperative diagnosis was a perimedullary arteriovenous fistula (AVF) with multiple feeders, we found concurrent dural AVF and perimedullary AVFs during surgery. We introduced an endoscope and performed endoscope-integrated ICG video-angiography because it was difficult to identify the angioarchitectures of the perimedural and dural AVFs on the ventral surface of the spinal cord under microscopic view alone. Endoscope-integrated ICG video-angiography gave us clear and magnified angioarchitectures of these lesions. The fistulous point and the varix of the perimedullary AVF was coagulated and dissected under endoscopic view, and the draining vein of the dural AVF was also coagulated and dissected at the origin from the dura mater under microscopic view. CONCLUSIONS A posterior approach with the assistance of an endoscope and endoscope-integrated ICG video-angiography is feasible for spinal vascular diseases located ventrally.
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Affiliation(s)
- Akira Ito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
| | - Toshiki Endo
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai; Department of Neurosurgery, Kohnan Hospital, Sendai, Japan.
| | - Tomoo Inoue
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
| | - Hidenori Endo
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
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Nambu I, Uchiyama N, Misaki K, Mohri M, Nakada M. Concurrent cervical dural and multiple perimedullary arteriovenous fistulas presenting with subarachnoid hemorrhage: The source of bleeding was invisible at initial angiography. Surg Neurol Int 2017; 8:2. [PMID: 28217381 PMCID: PMC5288984 DOI: 10.4103/2152-7806.198729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 11/30/2016] [Indexed: 11/28/2022] Open
Abstract
Background: We report the concurrence of a spinal dural arteriovenous fistula (DAVF) and multiple perimedullary arteriovenous fistulas (PAVFs) presenting with subarachnoid hemorrhage (SAH). Moreover, the bleeding site was detected 1 month after onset. Case Description: A 56-year-old man was admitted to our hospital with an SAH. A DAVF and two PAVFs were detected at the C2 level by two rounds of digital subtraction angiography. The source of bleeding, an aneurysm on the feeding artery of PAVF, was detected at the second angiogram, which was performed 1 month after the onset of SAH. The aneurysm was not demonstrated at initial angiogram because of thrombosis in the aneurysm. The DAVF was interrupted by transarterial embolization, and the two PAVFs were subsequently treated with surgery. Conclusion: A part of the whole AVFs or the source of bleeding may be invisible in the acute stage just after hemorrhage. Repeated angiography is necessary to diagnose such complex AVFs especially in case of an SAH and treatment should be performed during the subacute stage.
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Affiliation(s)
- Iku Nambu
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Kouichi Misaki
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Masanao Mohri
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan
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Llácer JL, Suay G, Piquer J, Vazquez V. Dural arteriovenous fistula at the foramen magnum: Report of a case and clinical-anatomical review. Neurocirugia (Astur) 2016; 27:199-203. [DOI: 10.1016/j.neucir.2016.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 12/02/2015] [Accepted: 01/16/2016] [Indexed: 11/24/2022]
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Jeon JP, Cho YD, Kim CH, Han MH. Complex spinal arteriovenous fistula of the craniocervical junction with pial and dural shunts combined with contralateral dural arteriovenous fistula. Interv Neuroradiol 2015; 21:733-7. [PMID: 26464289 DOI: 10.1177/1591019915609128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/28/2015] [Indexed: 11/16/2022] Open
Abstract
A high cervical dural arteriovenous fistula (dAVF) is relatively rare and tends to have different features, as compared with a thoracolumbar dAVF. Here, we report a case involving a complex AVF located at the craniocervical junction that was fed by the dural and pial arteries, combined with a contralateral dAVF.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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Endo T, Shimizu H, Sato K, Niizuma K, Kondo R, Matsumoto Y, Takahashi A, Tominaga T. Cervical perimedullary arteriovenous shunts: a study of 22 consecutive cases with a focus on angioarchitecture and surgical approaches. Neurosurgery 2015; 75:238-49; discussion 249. [PMID: 24867200 DOI: 10.1227/neu.0000000000000401] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reports of cervical perimedullary arteriovenous shunt (PMAVS) are limited, and treatment strategies have not been established. OBJECTIVE To describe angioarchitecture and optimal treatment strategies for cervical PMAVS. METHODS We treated 22 patients with cervical PMAVS between 2000 and 2012 (8 women and 14 men; age, 9-80 years). According to the classification, our patients included type IVa (4 patients), type IVb (16 patients), and type IVc (2 patients). Seventeen patients presented with subarachnoid hemorrhage. RESULTS A total of 41 shunting points were localized in 22 patients, of which 34 points were located ventral or ventrolateral to the spinal cord. The anterior spinal artery (ASA) contributed to the shunts in 16 patients. Aneurysm formation was identified in 8 patients. Endovascular treatment was attempted in 3 patients, resulting in complete obliteration in 1 patient (type IVc). Overall, 21 patients underwent open surgery. An anterior approach with corpectomy was elected for 2 patients; the other 19 patients underwent the posterior approaches using indocyanine green videoangiography, intraoperative angiography, endoscopy (8 patients), and neuromonitoring. Twenty patients were rated as having a good recovery at 6 months after surgery. No recurrence was observed in any patients during the follow-up (mean, 59.7 months). CONCLUSION Shunting points of the cervical PMAVS were predominantly located ventral or ventrolateral to the spinal cord and were often fed by the ASA. Even for ventral lesions, posterior exposure assisted with neuromonitoring and endoscopy, and intraoperative angiography provided a view sufficient to understand the relationships between the shunts and the ASA and contributed to good surgical outcomes.
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Affiliation(s)
- Toshiki Endo
- Departments of *Neurosurgery and ‡Neuroendovascular Therapy, Tohoku University, Graduate School of Medicine; §Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
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Mendes GA, Caire F, Saleme S, Ponomarjova S, Mounayer C. Retrograde leptomeningeal venous approach for dural arteriovenous fistulas at foramen magnum. Interv Neuroradiol 2015; 21:244-8. [PMID: 25964442 DOI: 10.1177/1591019915582942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 72-year-old man presented with sudden right homonymous hemianopsia. Work-up imaging revealed a left occipital haematoma and an arteriovenous fistula supplied by the meningeal branches to the clivus from the left vertebral artery (VA) with a rostral venous reflux into cortical veins. A microcatheter was advanced through brainstem veins into the venous collector. A compliant balloon was placed in the left VA facing the origin of feeders. The balloon was inflated to protect the vertebrobasilar circulation from embolic migration. Onyx was injected by the transvenous catheter. Control angiogram revealed exclusion of the lesion. Informed consent was obtained from the patient.
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Affiliation(s)
- George Ac Mendes
- Department of Interventional Neuroradiology, University of Limoges, France
| | - François Caire
- Department of Neurological Surgery, University of Limoges, France
| | - Suzana Saleme
- Department of Interventional Neuroradiology, University of Limoges, France
| | - Sanita Ponomarjova
- Department of Interventional Neuroradiology, University of Limoges, France
| | - Charbel Mounayer
- Department of Interventional Neuroradiology, University of Limoges, France
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Kasliwal MK, Moftakhar R, O'Toole JE, Lopes DK. High cervical spinal subdural hemorrhage as a harbinger of craniocervical arteriovenous fistula: an unusual clinical presentation. Spine J 2015; 15:e13-7. [PMID: 25725364 DOI: 10.1016/j.spinee.2015.02.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 01/13/2015] [Accepted: 02/18/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Craniocervical dural arteriovenous fistula (dAVF) is rare as compared with the typical thoracolumbar dAVFs of the spine and usually presents with hemorrhagic manifestation, predominantly intracranial subarachnoid hemorrhage. PURPOSE We describe the first case of craniocervical dAVF with initial presentation as neck pain and spinal subdural hemorrhage. STUDY DESIGN Case report. METHODS We present the case of a 59-year-old woman who presented with sudden onset of neck pain at an outside institution emergency department (ED) and was discharged after negative cervical spine radiographs. Magnetic resonance imaging of the cervical spine performed because of persistent pain demonstrated presence of high cervical spinal subdural hematoma and she was managed conservatively. She subsequently presented to our ED a week later with headache and was found to have an intraventricular hemorrhage on computed tomography scan of the head, which on subsequent workup with an angiography revealed the presence of a craniocervical dAVF. RESULTS Surgical obliteration of the fistula was performed with use of intraoperative angiography as an adjunct to confirm complete fistula obliteration. She had an excellent clinical outcome with no deficits at her last follow-up at 9 months. CONCLUSIONS Even though hemorrhagic presentation is fairly common in craniocervical dAVFs, there is no report of a craniocervical dAVF presenting with spinal subdural hemorrhage. The present case further highlights the propensity of these vascular lesions to bleed and emphasizes the clinical importance of including these lesions in the differential diagnosis of hemorrhage in the vicinity of foramen magnum region, whether subarachnoid or subdural in location. Physicians treating spinal pathologies should be aware of this entity and clinical presentation, as an angiography needs to be considered in these cases to direct appropriate referral and treatment.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St, Suite 855, Chicago, IL 60612, USA.
| | - Roham Moftakhar
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St, Suite 855, Chicago, IL 60612, USA
| | - John E O'Toole
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St, Suite 855, Chicago, IL 60612, USA
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, 1725 W. Harrison St, Suite 855, Chicago, IL 60612, USA
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Sudhir G, Acharya S, Kalra K, Chahal R. Arteriovenous malformation mimicking tuberculosis of spine with myelitis. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2015. [DOI: 10.1016/j.injms.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nakagawa I, Park HS, Hironaka Y, Wada T, Kichikawa K, Nakase H. Cervical Spinal Epidural Arteriovenous Fistula with Coexisting Spinal Anterior Spinal Artery Aneurysm Presenting as Subarachnoid Hemorrhage—Case Report. J Stroke Cerebrovasc Dis 2014; 23:e461-e465. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 07/06/2014] [Accepted: 07/09/2014] [Indexed: 11/15/2022] Open
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Aggarwal A, Salunke P, Futane S, Mathuriya SN, Kumar A, Mukherjee KK, Radotra BD. Ruptured venous aneurysm of cervicomedullary junction. Surg Neurol Int 2014; 5:2. [PMID: 24575317 PMCID: PMC3927081 DOI: 10.4103/2152-7806.124977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 12/11/2013] [Indexed: 11/30/2022] Open
Abstract
Background: Ruptured venous aneurysm is often seen with arterio-venous malformation (AVM) or developmental venous anomaly (DVA). However, isolated venous aneurysm is unusual. Case Description: We present a case of ruptured venous aneurysm that presented with subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH). Digital substraction angiography (DSA) revealed a saccular contrast filling pouch in the left lateral aspect of cervicomedullary junction (CMJ). Endovascular intervention was not a viable option. During surgery, a saccular pliable structure approx. 1.5 × 1 cm was found in the subarachnoid space that was clipped and excised. There were no arterial feeders, no evidence of surrounding AVM, and no dilated perimedullary vein. Conclusion: This is perhaps the first reported case of ruptured venous aneurysm (without associated AVM) of CMJ, which was successfully managed surgically. The possible etiologies remain an unnoticed head trauma or a congenital vessel wall abnormality. Surgically clipping and excision remains the treatment of choice for such lesion.
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Affiliation(s)
| | | | - Sameer Futane
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - S N Mathuriya
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - Ajay Kumar
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - K K Mukherjee
- Department of Neurosurgery, PGIMER, Chandigarh, India
| | - B D Radotra
- Department of Pathology, PGIMER, Chandigarh, India
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Gilard V, Curey S, Tollard E, Proust F. Coincidental vascular anomalies at the foramen magnum: Dural arteriovenous fistula and high flow aneurysm on perimedullary fistula. Neurochirurgie 2013; 59:210-3. [PMID: 24211045 DOI: 10.1016/j.neuchi.2013.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/14/2013] [Accepted: 06/09/2013] [Indexed: 10/26/2022]
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