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

Abstract

ObjectiveArteriovenous 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.MethodsA 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.ResultsThe 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).ConclusionsSAH 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.

Angioarchitectural features of arteriovenous fistulas of cranio-cervical junction predicting the risk of clinical presentation and unfavorable outcome: insight from a multicenter cohort and pooled analysis.

“…Although our study did not involve treatment modality and outcomes, myelopathy may still be recommended as an indication for treatment of CCJ-AVF in patients with unfavorable neurological status. Some authors have mentioned that ascending drainage route into an intracranial vein and venous varices were considered the causes of SAH [19]. ecent Japan multicenter cohort studies have identi ed the inclusion of the anterior spinal artery (ASA) as the feeder and aneurysmal dilatations as the risk factors associated with hemorrhagic presentation [5].…”

Treatment of high cervical arteriovenous fistulas in the craniocervical junction region

“…High cervical CCJ AVFs can be located on the inner or outer surface of the dura mater, on the spinal nerves, or on the spinal cord surface and can be divided into the following four types: DAVFs, radicular AVFs (RAVFs), epidural AVFs (EAVFs), and perimedullary AVFs (PAVFs) (Figures 4, 5), in which DAVFs and RAVFs tend to occur at the C1 level and EAVFs and PAVFs tend to occur at the C2 level (10,33,53,54). High cervical CCJ AVFs may be single or multiple AVFs, and less than 10% of AVFs are multiple AVFs (4,7,55). Multiple AVFs may be homogeneous, such as bilateral DAVFs, bilateral RAVFs or bilateral EAVFs (4,53,(55)(56)(57).…”

“…They are mainly fed by the radicular (radiculomeningeal, radiculopial or radiculomedullary) arteries of the VA (Figure 5) and rarely fed by the branch of the low-positioned PICA (Figure 6) (3,36). Feeding arteries of high cervical CCJ AVFs may be bilateral or multiple segmental (7,33,35). Spinal pial arteries from the ASA and PSA (or posterior lateral spinal artery) can be involved in more than half of CCJ AVFs (33).…”

“…Spinal pial arteries from the ASA and PSA (or posterior lateral spinal artery) can be involved in more than half of CCJ AVFs (33). Sometimes, meningeal branches of the AphA and OA can be involved in the feeders for CCJ DAVFs (7,33,61). Due to hemodynamic stress, flow-related aneurysms can occur on the feeding artery (34,53,59,62).…”

“…CCJ AVFs are uniquely complex due to their inherent angioarchitecture (4)(5)(6). CCJ AVFs may present with intracranial hemorrhage due to AVF rupture or edema of the brainstem and upper cervical cord due to venous hypertension (7,8). For these CCJ AVFs, prompt treatment is needed, mainly including open surgery or endovascular treatment (EVT) (3).…”