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Hashikata H, Goto M, Maki Y, Nishida N, Ando M, Ishibashi R, Toda H, Iwasaki K. Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review. Acta Neurochir (Wien) 2023; 165:3985-3990. [PMID: 37059919 DOI: 10.1007/s00701-023-05578-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/31/2023] [Indexed: 04/16/2023]
Abstract
While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery.
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Affiliation(s)
- Hirokuni Hashikata
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan.
| | - Masanori Goto
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
- Department of Neurosurgery, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minami, Chuo, Kobe, Hyogo, 650-0047, Japan
| | - Yoshinori Maki
- Department of Neurosurgery, Hikone Chuo Hospital, 421 Nishiima, Hikone, Shiga, 522-0054, Japan
- Department of Rehabilitation, Hikari Hospital, 3-35-1 Saikawa, Otsu, Shiga, 520-0002, Japan
| | - Namiko Nishida
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
| | - Mitsushige Ando
- Department of Neurosurgery, Shiga General Hospital, 5-4-30 Moriyama, Shiga, 524-8524, Japan
| | - Ryota Ishibashi
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
| | - Hiroki Toda
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
| | - Koichi Iwasaki
- Department of Neurosurgery, Medical Research Institute KITANO HOSPITAL, PIIF Tazuke-kofukai, 2-4-20 Ogimachi Kita, Osaka, 530-8480, Japan
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Choi JH, Park JC, Ahn JS, Park W. Treatment of Dural Arteriovenous Fistula with Intradural Draining Vein at the Craniocervical Junction: Case Series with Special Reference to the Anatomical Considerations. World Neurosurg 2023; 175:e1226-e1236. [PMID: 37427702 DOI: 10.1016/j.wneu.2023.04.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/24/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Dural arteriovenous fistulas at the craniocervical junction (CCJ DAVFs) are a rare vascular disease. Endovascular treatment (EVT) and microsurgery are the primary treatment modalities for CCJ DAVFs. However, incomplete treatment or complications may occur after treatment because of the anatomical complexity. OBJECTIVE We analyzed the neurosurgical treatment experiences of CCJ DAVFs to recommend suitable classification and treatment options. METHODS CCJ DAVFs were anatomically classified into three types according to the feeding arteries and their relationships with the anterior spinal (ASAs) and lateral spinal arteries (LSAs). Type 1 was fed by the radiculomeningeal artery from the vertebral artery and was not associated with the ASA or LSA. Type 2 was fed by the radiculomeningeal artery, and the radicular artery supplied the LSA near the fistula point. Type 3 had the characteristics of type 1 or type 2 CCJ DAVFs, except the ASA also contributed to the fistula. RESULTS There were 5, 7, and 4 cases of type 1, type 2, and type 3 CCJ DAVFs, respectively. EVT was attempted in 12 patients, of whom only 1 (type 1) was completely cured without complications. Nine cases had residual lesions after EVT, and two had spinal cord infarction due to occlusion of the LSA. Fourteen patients underwent microsurgical treatment. In all 14 cases, CCJ DAVFs were completely obliterated after microsurgery. CONCLUSION In cases of type 1 CCJ DAVF, both microsurgical treatment and EVT may be considered. However, for type 2 and 3 CCJ DAVFs, microsurgery may be a superior treatment modality.
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Affiliation(s)
- June Ho Choi
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Su H, Yu J. Treatment of high cervical arteriovenous fistulas in the craniocervical junction region. Front Neurol 2023; 14:1164548. [PMID: 37441609 PMCID: PMC10335834 DOI: 10.3389/fneur.2023.1164548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
The craniocervical junction (CCJ) is a complex region. Rarely, arteriovenous fistulas (AVFs) can occur in the CCJ region. Currently, it is accepted that CCJ AVFs should only refer to AVFs at the C1-C2 levels. It is reasonable to assume that high cervical CCJ AVFs are being referred to when discussing CCJ AVFs. High cervical CCJ AVFs can be divided into the following four types: dural AVF, radicular AVF, epidural AVF and perimedullary AVF. Until now, it was difficult to understand high cervical CCJ AVFs and provide a proper treatment for them. Therefore, an updated review of high cervical CCJ AVFs is necessary. In this review, the following issues are discussed: the definition of high cervical CCJ AVFs, vessel anatomy of the CCJ region, angioarchitecture of high cervical CCJ AVFs, treatment options, prognoses and complications. Based on the review and our experience, we found that the four types of high cervical CCJ AVFs share similar clinical and imaging characteristics. Patients may present with intracranial hemorrhage or congestive myelopathy. Treatment, including open surgery and endovascular treatment (EVT), can be used for symptomatic AVFs. Most high cervical CCJ AVFs can be effectively treated with open surgery. EVT remains challenging due to a high rate of incomplete obliteration and complications, and it can only be performed in superselective AVFs with simple angioarchitecture. Appropriate treatment can lead to a good prognosis.
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Zhang K, Li C, Hou K, Yu J. Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend? Front Neurol 2021; 12:761006. [PMID: 34764934 PMCID: PMC8576071 DOI: 10.3389/fneur.2021.761006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.
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Affiliation(s)
- Kun Zhang
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Chao Li
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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Matsubara S, Toi H, Takai H, Miyazaki Y, Kinoshita K, Sunada Y, Yamada S, Tao Y, Enomoto N, Minami YO, Hirai S, Yagi K, Nakashima H, Uno M. Variations and management for patients with craniocervical junction arteriovenous fistulas: Comparison of dural, radicular, and epidural arteriovenous fistulas. Surg Neurol Int 2021; 12:411. [PMID: 34513175 PMCID: PMC8422467 DOI: 10.25259/sni_557_2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/15/2021] [Indexed: 12/31/2022] Open
Abstract
Background: Craniocervical junction arteriovenous fistulas (CCJAVFs) are known to be rare, but variations and clinical behaviors remain controversial. Methods: A total of 11 CCJAVF patients (M: F=9:2, age 54–77 years) were investigated. Based on the radiological and intraoperative findings, they were categorized into three types: dural AVF (DAVF), radicular AVF (RAVF), and epidural AVF (EDAVF). Results: There were four symptomatic patients (subarachnoid hemorrhage in two, myelopathy in one, and tinnitus in one) and seven asymptomatic patients in whom coincidental CCJAVFs were discovered on imaging studies for other vascular diseases (arteriovenous malformation in one, intracranial DAVF in two, ruptured cerebral aneurysm in two, and carotid artery stenosis in two). Of these 11 patients, 2 (18.2%) had multiple CCJAVFs. Of 14 lesions, the diagnoses were DAVF in 5, RAVF in 3, and EDAVF in 6 (C1–C2 level ratio =5:0, 2:1, 3:3). Patients with DAVF/RAVF in four lesions with intradural venous reflux underwent surgery, although an RAVF remained in one lesion after embolization/radiation. Since all six EDAVFs, two DAVFs, and one RAVF had neither feeder aneurysms nor significant symptoms, no treatment was provided; of these nine lesions, one DAVF and one RAVF remained unchanged, whereas six EDAVFs showed spontaneous obliteration within a year. Unfortunately, however, one DAVF bled before elective surgery. Conclusion: CCJAVFs have many variations of shunting site, angioarchitecture, and multiplicity, and they were frequently associated with coincidental vascular lesions. For symptomatic DAVF/RAVF lesions with intradural drainage, surgery is preferred, whereas asymptomatic EDAVFs without dangerous drainage may obliterate during their natural course.
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Affiliation(s)
- Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroyuki Toi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yuko Miyazaki
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Keita Kinoshita
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshihiro Sunada
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Shodai Yamada
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshifumi Tao
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Noriya Enomoto
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | | | - Satoshi Hirai
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | - Kenji Yagi
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
| | | | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Japan
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Ruptured Isolated Aneurysm of a Coronal Branch of the Anterior Spinal Artery: Case Report and Discussion of Treatment Strategies. World Neurosurg 2020; 145:119-126. [PMID: 32949802 DOI: 10.1016/j.wneu.2020.09.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Isolated spinal artery aneurysms are an extremely rare cause of subarachnoid hemorrhage. A limited number of case reports and case series have been reported in the literature. Treatment options include conservative management, surgical clipping/trapping, and endovascular procedures. Owing to the uncertain natural history of these lesions, there is no consensus about the optimal treatment. CASE DESCRIPTION A 64-year-old man presented with subarachnoid hemorrhage from a ruptured anterior spinal artery aneurysm at the C1 level. Following initial conservative management, surgical treatment was proposed owing to an increase in lesion size at angiographic follow-up. A partially thrombosed aneurysm was found during surgery, suggesting that spontaneous resolution of the aneurysm was occurring. Despite initial worsening of neurological symptoms, the patient gradually recovered after rehabilitation. CONCLUSIONS Treatment decisions for spinal aneurysms should be made on a case-by-case basis, the goal being to offer the patient the best option, while avoiding exposure to unnecessary invasive procedures. As spontaneous resolution of a spinal artery aneurysm is unpredictable, our case highlights the importance of performing a perioperative vascular study if surgery is planned.
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Umana GE, Scalia G, Chaurasia B, Fricia M, Passanisi M, Graziano F, Nicoletti GF, Cicero S. Perimedullary arteriovenous fistulas of the craniovertebral junction: A systematic review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:157-162. [PMID: 33100763 PMCID: PMC7546045 DOI: 10.4103/jcvjs.jcvjs_106_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/22/2020] [Indexed: 11/22/2022] Open
Abstract
Perimedullary arteriovenous fistulas (PMAVFs) are uncommon vascular malformations, and they rarely occur at the level of the craniovertebral junction (CVJ). The therapeutic management is challenging and can include observation alone, endovascular occlusion, or surgical exclusion, depending on both patient and malformation characteristics. A systematic literature search was conducted using MEDLINE, Scopus, and Google Scholar databases, searching for the following combined MeSH terms: (perimedullary arteriovenous fistula OR dural arteriovenous shunt) AND (craniocervical junction OR craniovertebral junction). We also present an emblematic case of PMAVF at the level of the craniovertebral junction associated to a venous pseudoaneurysm. A total of 31 published studies were identified; 10 were rejected from our review because they did not match our inclusion criteria. Our case was not included in the systematic review. We selected 21 studies for this systematic review with a total of 58 patients, including 20 females (34.5%) and 38 males (65.5%), with a female/male ratio of 1:1.9. Thirty-nine out of 58 patients underwent surgical treatment (67.2%), 15 out of 58 patients were treated with endovascular approach (25.8%), 3 out of 58 patients underwent combined treatment (5.2%), and only 1 patient was managed conservatively (1.7%). An improved outcome was reported in 94.8% of cases (55 out of 58 patients), whereas 3 out of 58 patients (5.2%) were moderately disabled after surgery and endovascular treatment. In literature, hemorrhagic presentation is reported as the most common onset (subarachnoid hemorrhage in 63% and intramedullary hemorrhage in 10%), frequently caused either by venous dilation, due to an ascending drainage pathway into an intracranial vein, or by the higher venous flow rates that can be associated with intracranial drainage. Hiramatsu and Sato stated that arterial feeders from the anterior spinal artery (ASA) and aneurysmal dilations are associated with hemorrhagic presentation. In agreement with the classification by Hiramatsu, we defined the PMAVF of the CVJ as a vascular lesion fed by the radiculomeningeal arteries from the vertebral artery and the spinal pial arteries from the ASA and/or lateral spinal artery. Considering the anatomical characteristics, we referred to our patient as affected by PMAVF, even if it was difficult to precisely localize the arteriovenous shunts because of the complex angioarchitecture of the fine feeding arteries and draining veins, but we presumed that the shunt was located in the point of major difference in vessel size between the feeding arteries and draining veins. PMAVFs of CVJ are rare pathologies of challenging management. The best diagnostic workup and treatment are still controversial: more studies are needed to compare different therapeutic strategies concerning both long-term occlusion rates and outcomes.
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Affiliation(s)
- Giuseppe Emmanuele Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
| | - Bipin Chaurasia
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Marco Fricia
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Maurizio Passanisi
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
| | - Francesca Graziano
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance "Garibaldi", Catania, Italy
- Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Postgraduate Residency Program in Neurological Surgery, Neurosurgical Clinic, University Hospital "Policlinico P. Giaccone", Palermo, Italy
| | | | - Salvatore Cicero
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Catania, Italy
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