Delayed presentation of a vertebral arterio-venous fistula secondary to penetrating cervical trauma: endovascular management using coil embolisation - a case report

Abstract

Vertebro-vertebral arteriovenous fistulae occur infrequently. We report on such a case with delayed presentation following penetrating neck injury. This was successfully treated via coil embolisation. A 40-year-old woman presented with a subjective tinnitus that was abolished by turning her head to the right. She had sustained penetrating neck trauma 6 months earlier. Doppler Ultrasound and magnetic resonance angiogram confirmed the presence of a vertebral arterio-venous fistula. Using a trans-femoral arterial approach, the left vertebral artery was embolised by deployment of multiple coils. The patient had no return of symptoms at 3 months follow up. Radiological diagnosis and endovascular management of this condition is discussed.

Vertebrojugular arterio-venous fistula and psudo-aneurism formation due to penetrating vertebral artery injury: case report and review of the literature

“…These combinations are very important for the treatment of highflow fistulas. Another technique including closure of fistula orifice by micro-catheterization via the vertebral vein has also been described (20,30). The total occlusion rates of up to 89-91% have been reported for endovascular interventions (2,12).…”

“…The concurrence of a vertebral artery pseudoaneurysm and arteriovenous fistula between the vertebral artery and internal jugular vein is extremely rare and mostly occurs following penetrating traumas of the craniocervical region or may be iatrogenic (1,16,19,20,26). Penetrating traumas include firearm injuries while iatrogenic reasons include surgery, jugular venous catheterization, diagnostic angiography and nerve blocks (19).…”

“…Most AVFs occur post-traumatically but congenital disorders such as fibromuscular dysplasia and neurofibromatosis may also create a predisposition (7,11,20). Traumatic fistulas are mostly seen at the second part of the artery where it courses within the foramen transversarium (26).…”

“…A 12% mortality rate has been reported for patients with acutely ligated vertebral artery during spinal surgery due to iatrogenic ruptures (4, 26). Some advocate endovascular reconstruction with coated stents in the presence of a patent artery (15,20,25). If the damage is on the dominant vertebral artery, reconstruction with a stent and coil is mandatory.…”

“…This procedure may be performed via surgical ligation or endovascular techniques including stenting, detachable balloon, coil and other agents (14,19,20,26). …”