Perimedullary arteriovenous fistulas of the craniovertebral junction: A systematic review

Surgical Management of Extradural Tumors at the Craniovertebral Junction - Insights from a Tertiary Care Center

BACKGROUND

Craniovertebral junction (CVJ) tumors are challenging due to their unique anatomical location. This study aimed to evaluate the complexities in dealing with such precarious CVJ extradural lesions over the decade.

METHODS

Twenty-seven patients of extradural CVJ tumors operated between 2009 and 2018 were included. The demographic details, neurological status, surgical approach, extent of resection, type of fixation, complications, and outcome at final follow-up were recorded for each patient.

RESULTS

The mean age of the patients was 39.5 ± 20 years. Most (17/27) of the patients had involvement of a single level. Clivus was the most common (9/17) involved region followed by atlas (7/17) vertebrae. Majority of the patients (13/27) were operated through the posterior-only approach. About 15 patients (55.5%) had instability or extensive lesions that necessitated posterior fixation. None of the patients underwent anterior fixation. Gross and near total excision were achieved in 10 patients (37%) and 3 patients (11%) respectively while 14 patients underwent subtotal excision of tumor. On histopathological analysis, clival chordoma (8/27) was found to be the most common pathology followed by giant cell tumor (6/27), plasmacytoma (4/27), and multiple myeloma (2/27). Most patients (13 out of 27) had the same neurological status after the surgery. Six patients (22%) improved post-operatively with decreased weakness and spasticity. Thirteen (48%) patients underwent adjuvant radiotherapy.

CONCLUSIONS

This retrospective study provides valuable insights into managing extradural CVJ tumors and highlights the importance of individualized approaches for optimal outcome.

Clinical features, treatment strategies and outcomes of craniocervical junction arteriovenous fistulas: a cohort study of 193 patients

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.

Enhanced Treatment Options for Dural Arteriovenous Fistulas at the Craniocervical Junction: Endovascular Embolization Versus Microsurgery? A Single-Center 23-Year Experience

OBJECTIVE

The occurrence of dural arteriovenous fistulas (DAVFs) at the craniocervical junction (CCJ) is an uncommon vascular malformation. The diagnosis and treatment of CCJ DAVFs present a formidable challenge. This study aims to investigate the effect of endovascular embolization and microsurgery on improving patient prognosis.

METHODS

This retrospective study included patients diagnosed with CCJ DAVFs who received treatment at the First Affiliated Hospital of Fujian Medical University between January 2000 and January 2023. The clinical records, imaging data, and treatment methods were obtained from the hospital's medical record system. The patients were classified into microsurgery and embolization groups based on the surgical technique employed for treatment. The primary outcome measures were surgical-associated neurological dysfunction (SAND) and long-term neurological outcomes. The Cox proportional hazard regression was utilized to determine hazard ratios and 95% confidence intervals (CI) to assess the relationship between treatment methods and prognosis. Kaplan-Meier survival analysis was employed to evaluate the incidence of SAND in both cohorts.

RESULTS

This study recruited 46 patients with an average age of 53.72 ± 13.83 years. In the microsurgery group, there were 12 cases (26.1%) observed. While in the embolization group, there were 34 cases (73.9%). Of these patients, 16 (34.8%) experienced SAND after treatment. In the microsurgery group, there were 8 cases (75.0%), while in the embolization group, only 8 cases (23.5%) were reported. Specifically, the embolization group exhibited a significantly lower risk of SAND [adjusted hazard ratio = 0.259, 95% CI = 0.096-0.700; P = 0.008)] compared to the microsurgery group. Additionally, the combined Borden grade 2-3 was found to be significantly associated with SAND (adjusted hazard ratio = 3.150, 95% CI = 1.132-8.766; P = 0.028). The results of the Kaplan-Meier survival analysis indicated a statistically significant difference in the occurrence of favorable functional outcomes between the 2 groups (log-rank P = 0.0081).

CONCLUSIONS

CCJ DAVFs are uncommon disorders characterized by a diverse range of clinical manifestations. The functional prognosis of endovascular treatment may be superior to microsurgery.

Incidental craniovertebral junction schwannoma: Surgical or radiosurgical management?

Craniovertebral junction (CVJ) schwannomas are rare tumors, showing direct involvement of the atlanto-occipital and atlanto-axial joints. Microsurgical removal is the standard of care to improve symptoms and local control, but stereotactic radiosurgery (SRS) is an option. Both, surgery, and SRS, may show risks of severe complications. A 41-year-old male was referred to our department after incidental finding of a right-sided C1 tumor. A CT angiogram with 3D reconstructions showed the close relationship between the tumor and the right vertebral artery (VA). A post-contrast enhancement MRI revealed the presence of an extradural mass, sited at the level of the CVJ, mainly at the level of the right articular mass of C1. After multidisciplinary assessment, involving the gamma-knife and neurosurgical teams, we performed a microsurgical resection of the tumor. Histology confirmed the diagnosis of schwannoma. At 1 year follow-up the patient is stable, with no recurrence of the tumor. CVJ schwannoma's current standard of care is surgical resection, but longitudinal studies are required, and should promoted promptly since the recent introduction of the new version of GKSRS that allow the treatment of CVJ's lesions.

Our Experience of Eight Patients with Dural Arteriovenous Fistula's at Foramen Magnum with Respect to Presentation, Angioarchitecture, and Endovascular Treatment Outcomes

Background Dural arteriovenous fistulas (DAVFs) around foramen magnum (FM) with peri medullary venous drainage, are uncommon and have wide spectrum of presentation. Literature about this lesion is sparse. We intent to analyze and report our experience with these cases with respect to presentation, evaluation, and endovascular treatment outcomes.

Materials and Methods All the eight patients who were diagnosed with DAVFs at FM and treated with transarterial embolization using ethylene viny alcohol were included in this study. Clinical record sheets, radiological, and angiographic data of these patients were retrieved from our departmental database.

Results Duration of symptoms ranged from 1 day to 3 years. Presentation with progressive ascending sensory symptoms and weakness (N = 4), acute headache (N = 2) acute quadriplegia (N = 1), and right ear bruit (N = 1) was seen. Exclusive feeders from occipital artery (OA) and vertebral artery (VA) were seen in two and four patients, respectively. Dual feeders from a combination of ascending pharyngeal artery and VA; from a combination of OA and VA were seen in one patient each. The exclusive venous drainage to spinal peri medullary veins (N = 3), brain stem peri medullary veins (N = 1), and both combined (N = 4). Two patients had a draining vein aneurysm. Complete obliteration of fistula was achieved in all patients. Complete resolution of symptoms was seen in six patients; two patients had significant improvement.

Conclusion The clinical presentation of dural AVF at foramen magnum is wide ranging and these lesions can be treated effectively and safely by transarterial embolization. Duration of symptoms strongly influences the final patient outcome.

Arteriovenous fistulas in the craniocervical junction region: With vs. without spinal arterial feeders

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.

Spinal dural cerebrospinal fluid fistula as a cause of spontaneous intracranial hypotension syndrome: Diagnosis and surgical treatment

Spontaneous intracranial hypotension (SIH) syndrome most often occurs following a cerebrospinal fluid (CSF) fistula that develops in the spinal space. Neurologists and neurosurgeons lack an understanding of the pathophysiology and diagnosis of this disease, which can make timely surgical care difficult. With the correct diagnostic algorithm, it is possible to identify the exact location of the liquor fistula in 90% of cases; subsequent microsurgical treatment can save the patient from the symptoms of intracranial hypotension and restore the ability to work. Female patient, 57 years old, was admitted with SIH syndrome. Magnetic resonance imaging (MRI) of the brain with contrast confirmed signs of intracranial hypotension. Computed tomography (CT) myelography was performed to pinpoint the location of the CSF fistula. The diagnostic algorithm and successful microsurgical treatment of a patient with spinal dural CSF fistula at the Th3-4 level using a posterolateral transdural approach. The patient was discharged on day 3 after the surgery when these complaints regressed completely. At the control examination of the patient 4 months postoperatively, there were no complaints. Identification of the cause and location of spinal the CSF fistula is a complex process that requires several stages of diagnosis. Examination of the entire back with MRI, CT myelography, or subtraction dynamic myelography is recommended. Microsurgical repair of a spinal fistula is an effective method for the treatment of SIH. The posterolateral transdural approach is effective in the repair of a spinal CSF fistula located ventrally in the thoracic spine.

Surgical Management of Craniovertebral Junction Schwannomas: A Systematic Review

Background: Craniovertebral junction (CVJ) schwannomas are rare, with surgery and stereotactic radiosurgery (SRS) being effective yet challenging options. We systematically reviewed the literature on CVJ schwannomas. Methods: PubMed, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA statement to include studies reporting CVJ schwannomas. Clinical features, management, and outcomes were analyzed. Results: We collected 353 patients from 101 included articles. Presenting symptoms were mostly neck pain (30.3%) and headache (26.3%), with most cranial neuropathies involving the XII (31.2%) and X (24.4%) nerves. Most tumors originated from C2 (30.9%) and XII (29.4%) nerves, being extracranial (45.1%) and intradural-extradural (44.2%). Erosion of C1–C2 vertebrae (37.1%), the hypoglossal canal (28.3%), and/or jugular foramen (20.1%) were noted. All tumors were operated, preferably with the retrosigmoid approach (36.5%), with the far-lateral approach (29.7%) or with the posterior approach and cervical laminectomy (26.9%), far-lateral approaches (14.2%), or suboccipital craniotomy with concurrent cervical laminectomy (14.2%). Complete tumor resection was obtained most frequently (61.5%). Adjuvant post-surgery stereotactic radiosurgery was delivered in 5.9% patients. Median follow-up was 27 months (range, 12–252). Symptom improvement was noted in 88.1% of cases, and cranial neuropathies showed improvement in 10.2%. Post-surgical complications occurred in 83 patients (23.5%), mostly dysphagia (7.4%), new cranial neuropathies (6.2%), and cerebrospinal fluid leak (5.9%). A total of 16 patients (4.5%) had tumor recurrence and 7 died (2%), with median overall survival of 2.7 months (range, 0.1–252). Conclusions: Microsurgical resection is safe and effective for CVJ schwannomas. Data on SRS efficacy and indications are still lacking, and its role deserves further evaluation.

Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend?

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.