Foramen magnum dural arteriovenous fistula treated by a microsurgical technique combined with a feeder occlusion using the transarterial coil embolization

Abstract

The treatment of dural arteriovenous fistulas (DAVFs) at the foramen magnum remains controversial by reason that DAVFs appearing from the foramen magnum represent only a minority of spinal DAVFs. We present our treatment for an asymptomatic patient suffering from a foramen magnum DAVF. A 53-year-old man presented to our hospital with the complaint of a floating sensation. Although there was no subarachnoid hemorrhage or cerebral infarction on magnetic resonance imaging, a magnetic resonance angiography revealed a number of dilated veins and a large varix surrounding the medulla oblongata. Cerebral digital subtraction angiography (DSA) showed a foramen magnum DAVF fed by the neuromeningeal branch of the left ascending pharyngeal artery and occipital artery, draining into the posterior spinal vein. Occlusion of the fistula was achieved by a microsurgical technique combined with a feeder occlusion using transarterial coil embolization, without complications. We verified the complete occlusion on post-operative cerebral DSA. While this combined therapy was already established for the treatment of DAVFs, there were no reports of the combined therapy for foramen magnum DAVFs. This treatment was considered to be useful for foramen magnum DAVFs, especially those DAVFs at the foramen magnum with a number of dilated veins and a large varix.KeywOrds: Ascending pharyngeal artery, Combination therapy, Dural arteriovenous fistula, Foramen magnum, Transarterial coil embolization ÖZForamen magnum'daki dural arteriovenöz fistüllerin (DAVF) tedavisi spinal DAVF'in çok azı foramen magnumda yerleştiği için tartışmalıdır. Makalede asemptomatik bir hastada tesbit edilen foramen magnum DAVF'ünde uyguladığımız tedaviyi sunuyoruz. 53 yaşında erkek hasta hastanemize duyularında dalgalanma şikayeti ile başvurdu. Hastanın manyetik rezonans incelemesinde subaraknoid kanama veya serebral enfarkt olmamakla birlikte manyetik rezonans anjiyografi medulla oblongata çevresinde çok sayıda genişlemiş ven ve bir adet büyük bir varis olduğunu gösterdi. Serebral dijital subtraksiyon anjiyografi (DSA) sol asendan farengeal arterin nöromeningeal dalından ve oksipital arterden beslenen, posterior spinal vene drene olan bir foramen magnum DAVF'nü gösterdi. Fistülün oklüzyonu mikrocerrahi teknikle kombine olarak uygulanan besleyici damarın transarteriyal koil ile embolizasyonu yoluyla komplikasyonsuz olarak sağlandı. Postoperatif serebral DSA ile tam oklüzyonu doğruladık. DAVF'ler için kombine tedavi daha önce tanımlanmış olmakla birlikte, foramen magnumda yerleşmiş DAVF'ler bu yöntem hiç yayınlanmamıştır. Bu tedavi yöntemi foramen magnum DAVF'leri için, özellikle çok sayıda dilate ven ve geniş varisi olan olgularda, oldukça kullanışlıdır.AnAhtAr sÖZCÜKler: Asendan farengeal arter, Kombine tedavi, Dural arteriovenöz fistül, Foramen magnum, Transarteriyal koil embolizasyonu

A case of filum terminale arterial venous fistula needed a long arterial access for trans-arterial shunt obliteration

“…16 There are some reports about the endovascular treatment for AVFFT. [12][13][14][17][18][19][20][21][22] In an evaluation of the recent literature, we found 10 cases published in detail, summarized in Table 1. Arterial feeders of the shunts of AVFFT reported were mainly ASA, which go upwards to the top and turn to the shunt point of the fistulae.…”

“…There have been no reports about the adequate interval between feeder occlusion and TAE after feeder occlusion; however, there was a report about the direct shunt obliteration after the endovascular feeder occlusion. 21 A precise description of the challenges and traps included in such endovascular treatment has been discussed. 22 We consider DSA should be performed at the early stage after a feeder occlusion.…”

Medullary hemorrhage caused by foramen magnum dural arteriovenous fistula successfully obliterated using combination of endovascular and surgical treatments: A case report and literature review

“…[27] Many surgeons preferred suboccipital approach with partial or hemilaminectomy for foramen magnum DAVFs. [3273034] In our case, suboccipital approach without laminectomy of C1 was enough for resecting the dural leaflets and disconnecting leptomeningeal veins due to knowing the exact location of the fistula from angiographic CT.…”

“…We reviewed the published case reports which have sufficient clinical description and clearly demonstrated figures of foramen magnum DAVFs. [39131620212223242526272829303132333435] The collected data in this review include demographic data (i.e., gender and age of patient), presenting symptoms, the findings of image studies, arterial feeders of the fistula, location of the draining veins, the presence of venous varix, treatment of the fistula, and neurological outcomes following treatment [Table 1]. From the literature review, there were 27 cases, including our case, with 27 foramen magnum DAVFs.…”

Dural arteriovenous fistulae at the lateral foramen magnum: A series of two microsurgical cases

“…Microsurgery allows direct visualization and targeted interruption of the arteriovenous system within dural meningeal anastomoses and retrograde blood flow. It also facilitates access to smaller feeding arteries and minimizes risk of infarction from accidental occlusion of normal anastomotic vessels 4 . Minimally invasive endovascular approach is possible, but not always practically feasible in tackling DAVFs, especially if vessels are stenosed or torturous.…”