Endovascular Management of Pediatric High-Flow Vertebro-Vertebral Fistula with Reversed Basilar Artery Flow

Abstract

<jats:p> Vertebral artery arteriovenous fistula (VAVF) is mostly known as a post-traumatic and/or iatrogenic arteriovenous complication. However, spontaneous high-flow VAVF associated with flow reversal in the basilar artery has not been reported in children. We describe a unique asymptomatic presentation of a spontaneous high-flow VAVF associated with flow reversal in the basilar artery in a pediatric patient. The literature for classification, pathophysiology, treatment strategies, and post-procedural complications is also reviewed. </jats:p>

Vertebro-vertebral fistula presenting as a pulsatile tinnitus

“…Even more rare is a vertebro-vertebral fistula created by a spontaneous arterial dissection with a resulting pseudoaneurysm 9 12. Vertebro-vertebral fistulas have been reported in association with connective tissue diseases including fibromuscular dysplasia, neurofibromatosis, Ehler-Danlos syndrome and Marfan’s syndrome 12. In our patient, we could not identify a plausible cause to this fistula.…”

Lower vertebral-epidural spinal arteriovenous fistulas: a unique subtype of vertebrovertebral arteriovenous fistula, treatable with coil and Penumbra Occlusion Device embolization

“…Considering all VVAVF, the most common presenting sign of a vertebral-epidural spinal AVF is an objective bruit,13 with other recognized clinical presentations including radiculopathy due to local mass effect from epidural venous compression,14 myelopathy related to retrograde intradural venous drainage/congestion,15 subarachnoid or epidural hemorrhage,16 high-output congestive heart failure,9 and vertebrobasilar insufficiency secondary to arterial steal 17. The natural history of direct lower vertebral-to-epidural single-hole AVF is unknown, though given the presence of very high flow into a capacious venous collector, the eventual development of high-output cardiac failure would not be unexpected.…”

“…Given the morbidity and technical demands of surgery, including the potential for significant blood loss and the need for wide operative exposure of the upper or lower cervical regions, and in light of continued improvements in endovascular technology, embolization has emerged as a primary approach for treatment of these fistulas. Detachable latex balloons23–25 (not available in the USA) and coils7 8 17 19 have the longest track record for this purpose, although more recently, liquid embolic agents26 27 have also been used for spinal AVF embolization. However, unlike coils, which can be retrieved before detachment if the pattern of deployment appears unfavorable, liquid embolic agents are not retrievable after injection, and pose the potential risk of distal embolization through the epidural plexus, or proximal embolization into the vertebral artery.…”

Paraspinal arteriovenous fistula: Stuttgart classification based on experience and a review of the literature

“…7 Most acquired PAVSs show an epidural or paraspinal venous drainage. [8][9][10][11][12] Vertebrojugular or vertebrovertebral AVSs are a subtype of PAVSs, predominantly draining into paraspinal venous plexuses or epidural veins.…”

“…Due to unsatisfactory results, neurosurgical therapy is now only indicated in the case of compressive extradural hematoma. 8,12 Endovascular embolization became, meanwhile, the accepted first line treatment method for PAVSs. 23,26,55,56 Given the frequently present anastomoses and direct arterial supply to the myelon in the surrounding territory of PAVSs, particle embolization should be avoided.…”