Abstract
We report a case of craniocervical junction dural arteriovenous fistula (dAVF) presented with myelopathy and normal pressure hydrocephalus, and was treated with hybrid approach of embolization and surgical disconnection. A 68-year-old gentleman presented with 1 year history of unsteady gait and sphincter disturbance. Magnetic resonance imaging (MRI) showed abnormally enlarged and tortuous vessels over right cerebellomedullary cistern. Digital subtraction angiogram (DSA) showed Cognard's type-V dAVF at craniocervical junction. Catheter embolization was performed via external carotid artery and finally surgical disconnection was done with far lateral approach ( Fig. 1 ). Postoperative DSA showed no more arteriovenous shunting ( Fig. 2 ). Clinically the patient improved after a course of rehabilitation. Dural AVF at craniocervical junction is rare and its clinical presentation can be highly variable from subarachnoid hemorrhage to brainstem dysfunction. Identification of the exact fistula site is essential in surgical planning. Surgery is effective and safe to achieve complete obliteration and good clinical outcome. 1 2 3 4 5 6
The link to the video can be found at: https://youtu.be/xI48stSlWpY .
Keywords: dural arteriovenous fistula, craniocervical junction, far lateral approach, myelopathy, hydrocephalus
Fig. 1.
Intraoperative photos showing the anatomy (upper) and the fistula site (lower).
Fig. 2.
Post operative DSA (right) showing complete eradication of arteriovenous shunting.
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Acknowledgments
The authors would like to thank Mr. CK Ng for his intraoperative monitoring support and Dr. Jason Ho for his IT support.
Disclosures
The authors declare that they have no conflict of Interest.
References
- 1.Lin I C, Wu H C, Wu C H, Lin W C, Lieu A S. Craniocervical junction spinal dural arteriovenous fistula presenting with progressive myelopathy and sudden deterioration. Formos J Surg. 2017;50:223–226. [Google Scholar]
- 2.Hacein-Bey L, Konstas A A, Pile-Spellman J. Natural history, current concepts, classification, factors impacting endovascular therapy, and pathophysiology of cerebral and spinal dural arteriovenous fistulas. Clin Neurol Neurosurg. 2014;121:64–75. doi: 10.1016/j.clineuro.2014.01.018. [DOI] [PubMed] [Google Scholar]
- 3.Nakahara Y, Ogata A, Takase Y et al. Treatment of dural arteriovenous fistula presenting as typical symptoms of hydrocephalus caused by venous congestion: case report. Neurol Med Chir (Tokyo) 2011;51:229–232. doi: 10.2176/nmc.51.229. [DOI] [PubMed] [Google Scholar]
- 4.Ruiz-Juretschke F, Perez-Calvo J M, Castro E et al. A single-center, long-term study of spinal dural arteriovenous fistulas with multidisciplinary treatment. J Clin Neurosci. 2011;18(12):1662–1666. doi: 10.1016/j.jocn.2011.03.008. [DOI] [PubMed] [Google Scholar]
- 5.Wang J Y, Molenda J, Bydon A et al. Natural history and treatment of craniocervical junction dural arteriovenous fistulas. J Clin Neurosci. 2015;22(11):1701–1707. doi: 10.1016/j.jocn.2015.05.014. [DOI] [PubMed] [Google Scholar]
- 6.Zhao J, Xu F, Ren J, Manjila S, Bambakidis N C. Dural arteriovenous fistulas at the craniocervical junction: a systematic review. J Neurointerv Surg. 2016;8(06):648–653. doi: 10.1136/neurintsurg-2015-011775. [DOI] [PubMed] [Google Scholar]