Iatrogenic Vertebral Arteriovenous Fistula Involving Brachiocephalic Vein Due to Central Venous Catheterization: A Case Report

PURPOSE

To report a case of vertebral arteriovenous fistula (VAVF) caused by iatrogenic trauma of central venous catheterization (CVC) involving brachiocephalic vein (BCV).

CASE REPORT

A 79-year-old female was referred for assessment of a vertebral artery (VA) aneurysm at the V1 segment. The patient had no signs other than a vascular murmur on the right neck and was diagnosed 20 years after undergoing CVC. Right vertebral angiography revealed a high-flow shunt from the V1 segment of the right VA and draining into the right BCV. The fistula had a single communication between a pseudoaneurysm and large varix. We diagnosed the patient with CVCinduced VAVF (CIVAVF) involving BCV and obliterated the shunt by selective transarterial and transvenous embolization of the pseudoaneurysm under flow control using a balloon catheter with no complications.

CONCLUSION

This case highlights the point that CIVAVF involving BCV is rare but possible. In addition, there is a possibility that CIVAVF involving BCV does not demonstrate the findings of arterial steal or retrograde venous drainage and is undiagnosed for a long term due to lack of neurological manifestation and other subjective symptoms. We also showed that endovascular treatment can be feasible and useful for CIVAVF involving BCV.

A Rare Case of Post-Traumatic Cervical Ligamentous Tear Complicated by Vertebral Arteriovenous Fistula (vAVF), with Successful Endovascular Treatment

Post-traumatic vertebral arteriovenous fistula (vAVF) caused by motor vehicle accidents (MVA) is a rare condition in which there is abnormal communication between the vertebral artery and its adjacent veins. In a post-MVA setting, it is commonly associated with vertebral body fracture. In this paper, we report a case of a 19-year-old girl with a complete C2/C3 anterior and posterior ligament tear post MVA without any cervical bony injury. Initial plain computed tomography (CT) cervical scan showed a prevertebral hematoma. A CT angiogram (CTA) raised the suspicion of a pseudo-aneurysm at the right posterior C3 vertebral body. Further imaging with magnetic resonance imaging (MRI) demonstrated traumatic AVF at the C2/C3 level involving the V2/V3 right vertebral artery to the vertebral venous plexus. Digital Subtraction Angiography (DSA) further revealed a transected right vertebral artery at the C2/C3 level with an arteriovenous fistula and an enlarged vertebral venous plexus. The fistulous communication was successfully occluded with coils from a cranial and caudal approach to the transected segment right vertebral artery, with a total of eight coils. Post-MVA vertebral arteriovenous fistula (vAVF) is a rare sequela of vertebral bony injury at the cervical region, and is an even rarer association with an isolated ligamentous injury, whereby endovascular treatment with ipsilateral vertebral artery closure is a feasible treatment of vAVF.

Endovascular embolization and needle aspiration of a life-threatening cervical hematoma due to a neurofibromatosis type 1-associated arteriovenous fistula: illustrative case

BACKGROUND

In cases of neurofibromatosis in which the bleeding source is considered strongly related to a neurofibroma, an open surgical approach could risk uncontrollable bleeding from the vascular wall infiltration by neurofibroma. The case of a neurofibromatosis type 1 (NF1)-associated arteriovenous fistula presenting with a life-threatening cervical hematoma that was successfully treated with alternative treatment is described.

OBSERVATIONS

A 68-year-old woman diagnosed with NF1 presented with sudden onset of a spontaneous right cervical mass. Neck imaging on admission showed a massive subcutaneous hematoma with tracheal deviation and abnormal vascular structure in the hematoma. Digital subtraction angiography showed that an arteriovenous fistula (AVF) fed from a vertebral artery located within the hematoma cavity was the primary source of bleeding and feeding arteries from the occipital artery to the neurofibroma. Embolization of the cervical neurofibroma, as well as the AVF, was performed to reduce the secondary risk of bleeding, and was accomplished. After endovascular treatment, needle aspiration of the cervical hematoma was performed to reduce the mass effect.

LESSONS

When performing open surgery via tissues with neurofibromatosis proliferation, uncontrollable bleeding can occur. Therefore, endovascular embolization and needle aspiration of the hematoma should be considered in this setting.

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

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

Spontaneous obliteration of spontaneous vertebral arteriovenous fistula associated with fibromuscular dysplasia after partial surgery: A case report

We describe a patient with spontaneous obliteration of spontaneous vertebral arteriovenous fistula (VAVF) associated with fibromuscular dysplasia (FMD) after partial surgery. A 52-year-old hypertensive female woke up one morning with left shoulder pain and weakness of the left upper extremity. A few days later, she developed left-sided audible bruit. She was treated for left frozen shoulder and supportive treatment for audible bruit for four years. She was referred from her general physician to a neurosurgeon because of left arm weakness. Physical examination showed signs of cervical radiculomyelopathy. Magnetic resonance imaging (MRI) showed an extradural mass on the left side of the cervical spinal canal from level C2 to C6. Provisional diagnosis was epidural vascular tumour. Laminectomy and partial removal of the mass was performed at level C5 to C6. Pathological report revealed suspected vascular malformation. Postoperative MRI showed thrombosed epidural vascular structure. Angiography showed dysplastic changes of both vertebral arteries representing FMD with VAVF of the left vertebral artery at level C1-C2. Two years after surgery, follow-up MRI demonstrated complete spontaneous resolution of the large thrombosed epidural vein. Disappearance of her audible bruit immediately after surgery and gradual improvement of her cervical radiculomyelopathy were observed after two years of clinical follow-up. From the literature, we found another 11 patients with 12 VAVFs who had spontaneous obliteration or cure of their fistulas. In the present case, spontaneous obliteration of the fistula seems to correlate with surgery inducing closure of the epidural venous exit leading to thrombosis of the enlarged epidural draining vein.