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

Abstract

The authors describe an extremely rare case of foramen magnum dural arteriovenous fistula (DAVF), Cognard type V, presented with medullary hemorrhage caused by venous varix on the lateral medullary draining vein embedded into the medulla oblongata. Following mild myelopathy for 3 days, a 20-year-old male developed dyspnea, generalized seizures, loss of consciousness, and finally cardiac arrest. After successful resuscitation, computed tomography scan (CT) of the brain was obtained and showed acute medullary hemorrhage. Subsequent magnetic resonance imaging of the brain revealed diffuse venous congestion or edema of the medulla with multiple dilated flow voids surrounding the medulla, more prominent on the left side, with venous varix embedded into the left-sided of the lower medulla. He was sent to the emergency department of the local hospital and intubated promptly. A few minutes later, the patient had a cardiac arrest. Digital subtraction angiography (DSA) demonstrated DAVF of the foramen magnum supplied mainly by dural branches of bilateral hypertrophic posterior inferior cerebellar arteries (PICAs), slightly by the posterior meningeal branch of the left vertebral artery, and the jugular branch of the left ascending pharyngeal artery (APA) originating from the occipital artery. Transarterial embolization through the bilateral dural branches of the PICAs was successfully performed using N-butyl-2-cyanoacrylate (NBCA), resulting in complete obliteration. The patient had excellence recovery and lost to annual follow-up. Seven years later, he had a recurrent of the fistula presented with occipital headache. DSA with angiographic CT in three-dimensional reconstruction and maximum intensity projection reformatted images clearly demonstrated the exact location of the DAVFs at the posterior rim of the foramen magnum, mainly recruited by the hypertrophic jugular branch of the APA originating from the occipital artery. The fistula was successfully treated surgically following transarterial embolization through the jugular branch of the APA using NBCA. Follow-up DSA confirmed complete obliteration of the DAVF. The patient has remained clinically asymptomatic 2 years after the operation.

PNF technique combined with extracorporeal shock wave in the treatment of hemiplegia caused by upper cervical perimedullary arteriovenous fistula embolization:clinical experience and review of literature

“…1 30 At the same time, most patients with Spinal dural arteriovenous stula after surgical intervention did not have serious complications. 5 cases of them had sensory dysfunction or numbness, 1 28 30 37 38 6 cases of them had decreased strength or even gait instability, 30-32, 37, 38 1 cases had hemiplegia 31 and 1 case had quadriplegia, 33 However, the mild complications of the cases recovered quickly, only 3 more serious cases received rehabilitation treatment. 31,35,37 At present, the effect of extracorporeal shock waves on spasticity caused by central diseases is not clear.…”

“…Treatment options for SDAVF include endovascular embolization and surgical ligation of the stula [28][29][30][31][32][33][34][35][36][37][38] . Endovascular embolization is less invasive.…”

Clinical features, angio-architectural phenotypes, and treatment strategy of foramen magnum dural arteriovenous fistulas: a retrospective case series study

“…Microsurgery has also been useful in cases with symptoms caused by the mass effect of the dilated venous pouch and the shunt fistula (1). Chen et al reported that trigeminal neuralgia due to a foramen magnum DAVF compression was completely relieved after surgical disconnection (9). In addition, although seldom reported, surgery-related complications (intracranial hematoma, intracranial infection, etc.,) cannot be completely avoided.…”

“…However, in the past decade, with remarkable advances in the endovascular techniques providing highly flexible hydrophilic-coated catheters and new non-adhesive liquid embolic agents, such as Onyx and N-butyl-cyanoacrylate (NBCA) glue, endovascular embolization of the fistula has become an alternative option for treating the foramen magnum DAVFs (6)(7)(8). It has been reported that ∼80% of the foramen magnum DAVFs in the literature were treated endovascularly (9). Nevertheless, the incomplete obliteration and reoccurrence of the fistula after endovascular embolization could not be underestimated, and some cases even required staged or salvage combined surgeries (1,10).…”

“…It has been reported that ~80% of the foramen magnum DAVFs in the literature were treated endovascularly ( 9 ). Nevertheless, the incomplete obliteration and reoccurrence of the fistula after endovascular embolization could not be underestimated, and some cases even required staged or salvage combined surgeries ( 1 , 10 ). Recently, a combined surgical-endovascular technique in a hybrid operating room (Hybrid Angio-Surgical Suite, HASS) has emerged as a solution to the complexity of cerebrovascular surgery, and this technique has been an effective treatment option for DAVFs complicated by inaccessible arterial and transvenous approaches ( 11 , 12 ).…”