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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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Choi JH, Park JC, Ahn JS, Park W. Treatment of Dural Arteriovenous Fistula with Intradural Draining Vein at the Craniocervical Junction: Case Series with Special Reference to the Anatomical Considerations. World Neurosurg 2023; 175:e1226-e1236. [PMID: 37427702 DOI: 10.1016/j.wneu.2023.04.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/24/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Dural arteriovenous fistulas at the craniocervical junction (CCJ DAVFs) are a rare vascular disease. Endovascular treatment (EVT) and microsurgery are the primary treatment modalities for CCJ DAVFs. However, incomplete treatment or complications may occur after treatment because of the anatomical complexity. OBJECTIVE We analyzed the neurosurgical treatment experiences of CCJ DAVFs to recommend suitable classification and treatment options. METHODS CCJ DAVFs were anatomically classified into three types according to the feeding arteries and their relationships with the anterior spinal (ASAs) and lateral spinal arteries (LSAs). Type 1 was fed by the radiculomeningeal artery from the vertebral artery and was not associated with the ASA or LSA. Type 2 was fed by the radiculomeningeal artery, and the radicular artery supplied the LSA near the fistula point. Type 3 had the characteristics of type 1 or type 2 CCJ DAVFs, except the ASA also contributed to the fistula. RESULTS There were 5, 7, and 4 cases of type 1, type 2, and type 3 CCJ DAVFs, respectively. EVT was attempted in 12 patients, of whom only 1 (type 1) was completely cured without complications. Nine cases had residual lesions after EVT, and two had spinal cord infarction due to occlusion of the LSA. Fourteen patients underwent microsurgical treatment. In all 14 cases, CCJ DAVFs were completely obliterated after microsurgery. CONCLUSION In cases of type 1 CCJ DAVF, both microsurgical treatment and EVT may be considered. However, for type 2 and 3 CCJ DAVFs, microsurgery may be a superior treatment modality.
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Affiliation(s)
- June Ho Choi
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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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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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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Oushy S, Borg N, Lanzino G. Contemporary Management of Cranial Dural Arteriovenous Fistulas. World Neurosurg 2022; 159:288-297. [PMID: 35255630 DOI: 10.1016/j.wneu.2021.09.045] [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: 08/16/2021] [Accepted: 09/10/2021] [Indexed: 11/19/2022]
Abstract
Cranial dural arteriovenous fistulas (dAVFs) are rare acquired neurovascular disorders that have the potential to profoundly alter the local and global cerebral venous drainage. Factors such as location, angioarchitecture, degree of shunting, and mode of presentation all appear to have some bearing on the natural history of dAVFs, which can vary from almost entirely benign to life-threatening. Accurate and evidence-based risk stratification is, therefore, key to informing important management decisions. The treatment strategies are nuanced and, for an already rare entity, can vary tremendously from 1 fistula to another. It is only through a thorough understanding of their behavior and the treatment options available that we will be able to deliver tailored treatment to the correct dAVF and the correct patient. We aimed to provide an up-to-date summary of the reported data on the natural history and predictors of aggressive behavior for cranial dAVFs in general, followed by site-specific management considerations.
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Affiliation(s)
- Soliman Oushy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Borg
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Zhang K, Li C, Hou K, Yu J. Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend? Front Neurol 2021; 12:761006. [PMID: 34764934 PMCID: PMC8576071 DOI: 10.3389/fneur.2021.761006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.
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Affiliation(s)
- Kun Zhang
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Chao Li
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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Broekx S, Houben R, Stockx L, Boulanger T, Gelin G, Weyns F, De Beule T. The external carotid artery as a rare feeder of a spinal dural arteriovenous fistula causing cervical myelopathy: A review of the literature. BRAIN & SPINE 2021; 1:100299. [PMID: 36247399 PMCID: PMC9560705 DOI: 10.1016/j.bas.2021.100299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 08/30/2021] [Accepted: 09/21/2021] [Indexed: 06/16/2023]
Abstract
INTRODUCTION A causal relationship between SDAVF's and cervical myelopathy is exceedingly rare. 1-2% of these lesions are located at the craniocervical junction of which 12% are caused by arterial feeders from the external carotid artery. A correct diagnosis can be challenging with a high rate of initial misdiagnosis. RESEARCH QUESTION Which aspects constitute the most important potential pitfalls in the diagnostic workup and treatment of SDAVF's with feeders from the external carotid artery causing cervical myelopathy? MATERIAL AND METHODS We performed a PRISMA-guided review of the literature in which fourteen articles were included. We illustrate the diagnostic hazards through one of our own cases. RESULTS SDAVF's at the cervical segment contain unique clinical and radiographic characteristics which differ from those elsewhere. Cervical myelopathy is caused by a SDAVF in 2.3% of cases. Pitfalls are numerous and diagnosis can be challenging, due to a broad differential diagnosis, potential isolated lower extremity involvement and absence of spinal cord edema on MRI. MR-alterations not always correlate with fistula localization. DISCUSSION AND CONCLUSION A SDAVF should be part of the differential diagnosis in patients with subacute tetraparesis. When MRI shows signal alterations in combination with enlarged perimedullary vessels, a SDAVF should be suspected. Spinal angiography should include the vertebrobasilar system, as well as the internal and external carotid arteries. Early and adequate occlusion by means of an endovascular or neurosurgical approach of the draining radicular veins should be pursued. A multidisciplinary approach is key in the diagnostic workup and treatment of these patients.
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Key Words
- Ascending pharyngeal artery
- CASPR2, Contactin associated protein 2
- CLIPPERS, Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids
- CRP, C-reactive protein
- Cervical myelopathy
- DPPX, Dipeptidyl-peptidase-like protein
- EMG, Electromyogram
- External carotid artery
- GABAb, Gamma aminobutyric acid
- LETM, Longitudinally extensive transverse myelitis
- LGLI1, Glioma-associated oncogene 1
- MEP, Motor-evoked potential
- MOG, Myelin oligodendrocyte glycoprotein
- MRC, Medical research council
- NMO, Neuromyelitis optica
- Occipital artery
- PCR, Polymerase chain reaction
- POEMS, Polyneuropathy organomegaly endocrinopathy monoclonal gammopathy skin changes
- PRISMA, Preferred reporting items for systematic reviews and meta-analyses
- QUORUM, Quality of reporting of meta-analyses
- Spinal dural arteriovenous fistula
- mGLUR1, Metabotropic glutamate receptor 1
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Affiliation(s)
- Senne Broekx
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
- Department of Neurology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
| | - Rik Houben
- Department of Neurology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
| | - Luc Stockx
- Department of Interventional Radiology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
| | - Thierry Boulanger
- Department of Interventional Radiology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
| | - Geert Gelin
- Department of Neuroradiology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
| | - Frank Weyns
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, 3500, Hasselt, Belgium
| | - Tom De Beule
- Department of Interventional Radiology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium
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Treatment strategy to maximize the treatment outcome of spinal dural arteriovenous fistula after initial endovascular embolization attempt at diagnostic angiography. Sci Rep 2021; 11:10004. [PMID: 33976351 PMCID: PMC8113326 DOI: 10.1038/s41598-021-89407-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/19/2021] [Indexed: 12/04/2022] Open
Abstract
Initial attempt of endovascular treatment (EVT) for spinal dural arteriovenous fistula (SDAVF) is preferred because of concurrent diagnosis and treatment. However, outcomes following further treatment with initial EVT are not well studied. We retrospectively reviewed 71 patients with SDAVF to evaluate treatment outcomes of SDAVF after an initial EVT attempt. Pretreatment and posttreatment functional states were assessed by the Aminoff-Logue scale (ALS). In the case of incomplete occlusion or recurrence, overall outcomes after further treatments were compared. Of the 71 patients, 56 underwent initial EVT. Complete occlusion was achieved by initial EVT in 37 of 56 patients (66.1%). Multiple feeders were more frequently observed in patients with incomplete occlusion than complete occlusion after initial EVT (73.7% vs. 27%, P < 0.001). Among 19 patients with incomplete occlusion upon initial EVT, 14 underwent additional surgery, 13 of whom (92.9%) obtained improved or stationary functional outcomes. Functional improvement was not observed in patients who had repeated EVT or follow-up without further treatment. Recurrence was observed in 8 of 37 patients with complete occlusion upon initial EVT. Additional surgery achieved improved functional outcomes in cases of incomplete occlusion of SDAVF after the initial EVT attempt or recurrence rather than repeated EVT or follow-up.
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Surgical Management for Craniocervical Junction Arteriovenous Fistula Targeting the Intradural Feeder. World Neurosurg 2020; 144:e685-e692. [PMID: 32942059 DOI: 10.1016/j.wneu.2020.09.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Craniocervical junction arteriovenous fistula (CCJAVF) has a variety of forms, including dural and perimedullary arteriovenous fistulas. Owing to this anatomic variety, the terminologies for classifying CCJAVF, most of which aim to describe angiographic structures, have yet to be firmly established, and the current taxonomic classifications do not facilitate surgical strategies. Herein we focused on the existence of intradural feeder vessels, allowing the identification of 2 types of CCJAVF. This retrospective study aimed to assess the usefulness of our diagnostic classification for CCJAVF surgery. METHODS We divided CCJAVF into 2 types: CCJAVF with an intradural feeder vessel and CCJAVF without an intradural feeder vessel. For the former type, we set the surgical goal of interrupting the intradural feeder and the draining veins behind the posterior spinal nerve. For the latter type, the surgical goal was to interrupt the draining veins behind the posterior spinal nerve. We retrospectively analyzed the outcomes of our surgical cases. RESULTS Of 12 patients with CCJAVF, 8 underwent direct surgery. No patients showed exacerbation of neurological symptoms after surgery. One patient needed a second operation for residual shunt, and another patient developed an asymptomatic angiographic recurrence in the epidural space detected on follow-up imaging. The overall outcomes of surgical cases were good with an average modified Rankin Scale score of 1.0. CONCLUSIONS Our results indicate that our diagnostic classification for CCJAVF has the potential to simplify CCJAVF treatment without compromising patient outcomes.
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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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Subramaniam SM, Ishii K, Sheng CJ, Nakatomi H, Takai K, Saito N. Successful surgical strategy for ventral thoracic spinal perimedullary spinal arteriovenous fistulas: Case report. Surg Neurol Int 2020; 10:251. [PMID: 31893152 PMCID: PMC6935962 DOI: 10.25259/sni_516_2019] [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: 10/30/2019] [Accepted: 11/04/2019] [Indexed: 11/22/2022] Open
Abstract
Background: Spinal arteriovenous fistulas (AVFs) are vascular lesions that often pose significant surgical challenges. This is particularly true for those located close to the anterior spinal artery. Here, we analyzed the surgical options for treating an anterior perimedullary AVF (pAVFs). Case Description: A 66-year-old male with the right lower extremity weakness was diagnosed with a spinal dural AVF at the L1 level. It was initially treated with open surgery followed by CyberKnife radiosurgery at another institution. Five years later, he presented with a persistent pAVF fistula now involving the T11 level; the major feeder originated on the left at the T7–T8 level (e.g., involving a left-sided “duplicated” anterior spinal artery). Utilizing a three-dimensional (3D) computer tomography (CT) guided approach; he underwent a left-sided posterolateral T10–T12 laminectomy, sufficient to allow for 30–40° of anterior spinal cord rotation. This was performed under neurophysiological monitoring without any significant changes. Surgery included indocyanine green video angiography, temporary feeder clipping, and complete occlusion of the AVF, followed by complete clipping/resection as confirmed on postoperative magnetic resonance imaging. Conclusion: Utilizing a 3D CT image, a ventral pulmonary arteriovenous malformation was excised utilizing a left-sided posterolateral approach allowing for 30–40° of cord rotation.
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Affiliation(s)
- S Muruga Subramaniam
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo.,Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.,Department of Surgery, Division of Neurotrauma, Hospital Tengku Ampuan Rahimah, Selangor Darul Ehsan
| | - Kazuhiko Ishii
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo
| | - Chen Jui Sheng
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo
| | - Keisuke Takai
- Department of Medicine, Melaka Manipal Medical College, Manipal University, Melaka, Malaysia
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo
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Vitowanu J, Idowu O. Multiple skipped craniospinal arteriovenous malformations complicated with hydrocephalus and syringomyelia. JOURNAL OF WEST AFRICAN COLLEGE OF SURGEONS 2020; 10:36-40. [PMID: 35814965 PMCID: PMC9267042 DOI: 10.4103/jwas.jwas_52_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Abstract
Arteriovenous malformations (AVMs) can occur within the intracranial or spinal region. When AVMs occur within the central nervous system, they are usually solitary. Central nervous system AVMs are known to be more common within the intracranial compartment when compared with the spinal region. AVMs within the intracranial compartment can be complicated with hydrocephalus, whereas AVM within the spinal cord may be associated with syringomyelia, just like a posterior fossa AVM. The co-existence of cranial and spinal AVMs has only been reported in very few cases in the literature. We report a case of multiple and skipped cerebral and juvenile spinal AVM associated with hydrocephalus and cervicothoracic syringomyelia in a 26-year-old female.
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13
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Nguyen A, Maynard K, Coggins W, Raghuram K. Successful embolization of an upper cervical spinal dural fistula despite anterior spinal artery anastomosis. Br J Neurosurg 2019:1-3. [PMID: 31760851 DOI: 10.1080/02688697.2019.1694136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A female in her 40s presented with classic symptoms of subarachnoid hemorrhage and limited mobility of the bilateral upper extremities. Imaging demonstrated a minor amount of subarachnoid blood, and a follow-up computed tomography angiogram revealed a spinal dural arteriovenous fistula (SDAVF) located at C2-3. The C2-3 radicular artery proximal to the fistula feeder anastomosed with the anterior spinal artery, challenging the safety of embolization. However, surgical treatment of the SDAVF would require a suboccipital craniotomy due to its proximity to the foramen magnum, so possible embolization based on lidocaine provocative test results was decided upon. Neurologic examination of the patient following lidocaine provocative testing suggested that embolization could be performed safely. Glue embolization was successfully performed, and the patient awoke without complications. Subsequent imaging revealed no filling of the medullary vein that previously drained the fistula.
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Affiliation(s)
- Anthony Nguyen
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Ken Maynard
- Division of Neurosurgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - William Coggins
- School of Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Karthikram Raghuram
- Department of Radiology, The University of Texas Medical Branch, Galveston, TX, USA
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14
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Sato H, Wada H, Noro S, Saga T, Kamada K. Subarachnoid Hemorrhage with Concurrent Dural and Perimedullary Arteriovenous Fistulas at Craniocervical Junction: Case Report and Literature Review. World Neurosurg 2019; 127:331-334. [PMID: 30825618 DOI: 10.1016/j.wneu.2019.02.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The association between a dural arteriovenous fistula (dAVF) and perimedullary arteriovenous fistula (AVF) is rarely observed at the craniocervical junction (CCJ). We present a case of subarachnoid hemorrhage (SAH) with concurrent dAVF and perimedullary AVF at the CCJ. Here, we describe the cause of bleeding and the process of determining whether it was a varix or an arterial aneurysm. CASE DESCRIPTION A 69-year-old man with SAH visited the emergency department. A dAVF at the CCJ was detected on digital subtraction angiography (DSA). However, after 3 weeks, when the DSA was repeated, a perimedullary AVF and varix were identified. We performed an endovascular treatment, but because the perimedullary AVF remained, we performed a direct surgery. The patient was discharged without weakness, but this left abducens nerve palsy remained. CONCLUSIONS In recent reports, SAH caused by concurrent dAVF and perimedullary AVF raised the possibility of an arterial aneurysm. However, in this case, the possibility of venous bleeding was high and a varix rather than an aneurysm was observed. On the basis of the reported cases, concurrent dAVF and perimedullary AVF at the CCJ is a "middle-flow arteriovenous shunt" that may induce a varix or an arterial aneurysm.
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Affiliation(s)
- Hirotaka Sato
- Department of Neurosurgery, Asahikawa Medical University, Hokkaido, Japan.
| | - Hajime Wada
- Department of Neurosurgery, Asahikawa Medical University, Hokkaido, Japan
| | - Shohei Noro
- Department of Neurosurgery, Asahikawa Medical University, Hokkaido, Japan
| | - Takehiro Saga
- Department of Neurosurgery, Asahikawa Medical University, Hokkaido, Japan
| | - Kyousuke Kamada
- Department of Neurosurgery, Asahikawa Medical University, Hokkaido, Japan
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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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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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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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McGurgan IJ, Lonergan R, Killeen R, McGuigan C. Cervical spine arteriovenous fistula associated with hereditary haemorrhagic telangiectasia. BMJ Case Rep 2017; 2017:bcr2016218172. [PMID: 28174188 PMCID: PMC5307285 DOI: 10.1136/bcr-2016-218172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 11/03/2022] Open
Abstract
Reported is a case of a man aged 55 years who presented with progressive spastic paraparesis. Examination demonstrated multiple cutaneous telangiectases. Subsequent development of upper limb weakness, acute urinary retention and eventual respiratory compromise resulted in the requirement for intensive care unit admission and mechanical ventilation. MRI spine revealed diffuse T2 hyperintensity in the cervical cord with enhancement and cord expansion. Immunomodulatory therapy for a presumed diagnosis of transverse myelitis yielded no response, so a vascular aetiology was suspected. Spinal angiography demonstrated an arteriovenous fistula involving the upper cervical cord. Endovascular embolisation was successfully performed and a marked clinical improvement was achieved. Cervical arteriovenous fistulas can cause progressive myelopathy, subarachnoid haemorrhage and brainstem dysfunction. Management typically comprises endovascular embolisation or surgical interruption. A clinical diagnosis of hereditary haemorrhagic telangiectasia was also made in this case, and spinal arteriovenous fistula formation has been associated with this condition.
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Affiliation(s)
- Iain John McGurgan
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - Roisin Lonergan
- Department of Neurology, St Vincent's University Hospital, Dublin, Ireland
| | - Ronan Killeen
- Department of Radiology, St Vincent's University Hospital, Dublin, Ireland
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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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20
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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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