High cervical arteriovenous fistulas fed by dural and spinal arteries and draining into a single medullary vein

Abstract

Object The authors previously reported a case of complex arteriovenous fistula (AVF) at C-1 with multiple dural and spinal feeders that were linked with a common medullary venous channel. The purpose of the present study was to collect similar cases and analyze their angioarchitecture to gain a better understanding of this malformation. Methods Three such cases, affecting 2 males and 1 female in their 60s who had presented with hematomyelia (2) or progressive myelopathy (1), were treated surgically, and the operative findings from all 3 cases were compared using digital subtraction angiography (DSA) to determine the angioarchitecture. Results The C-1 and C-2 radicular arteries and anterior and posterior spinal arteries supplied feeders to a single medullary draining vein in various combinations and via various routes. The drainage veins ran along the affected ventral nerve roots and lay ventral to the spinal cord. The sites of shunting to the vein were multiple: dural, along the ventral nerve root in the subarachnoid space, and on the spinal cord, showing a vascular structure typical of dural AVF, that is, a direct arteriovenous shunt near the spinal root sleeve fed by one or more dural arteries and ending in a single draining vein, except for intradural shunts fed by feeders from the spinal arteries. In 2 cases with hemorrhagic onset the drainer flowed rostrally, and in 1 case associated with congestive myelopathy the drainer flowed both rostrally and caudally. Preoperative determination of the shunt sites and feeding arteries was difficult because of complex recruitment of the feeders and multiple shunt sites. The angioarchitecture in these cases was clarified postoperatively by meticulous comparison of the DSA images and operative video. Direct surgical intervention led to a favorable outcome in all 3 cases. Conclusions A high cervical complex AVF has unique angioarchitectural characteristics different from those seen in the other spinal regions.

Angioarchitecture of arteriovenous fistulas at the craniocervical junction: a multicenter cohort study of 54 patients

“…In recent reports, the angiographic findings of CCJ AVFs were interpreted as the coincidental development of DAVF and PAVF. 5,11,13 In the present study, we found that more than half of the CCJ AVFs (35 [59%] of 59 lesions) were fed by both the radiculomeningeal arteries from the VA and the spinal pial arteries from the ASA and/or LSA. Moreover, 10 lesions with these 2 kinds of feeders were imaged with superselective angiography, and these feeders drained into the same vein.…”

Cervical spine arteriovenous fistula associated with hereditary haemorrhagic telangiectasia

“…The angioarchitectural characteristics of arteriovenous fistulas can, however, be hard to accurately define; thus, classifying them as such can represent a challenge. The authors of one case series postulate that some previously reported cases of apparent high cervical dural fistulas may in fact have been complex forms with, for example, additional supply from the spinal arteries,1 and perimedullary fistulas were most likely misclassified as dural fistulas in a large 2006 review 6…”

“…An initial diagnosis of a cervical dural arteriovenous fistula was made on the basis that there appeared to be no continuity between the feeding artery and the anterior or posterolateral spinal arteries. This would be in keeping with a dural fistula, for which the feeding vessel is a radiculomeningeal artery that does not usually supply the spinal arteries,1 versus a perimedullary fistula on the pial surface which is supplied by the spinal arteries 2. Subsequent review of the angiographic findings, however, casts doubt over this assertion.…”

Concurrent cervical dural and multiple perimedullary arteriovenous fistulas presenting with subarachnoid hemorrhage: The source of bleeding was invisible at initial angiography

“…[ 2 ] However, DAVFs and PAVFs located at the craniocervical junction or cervical regions are associated with an increased incidence of SAH and cranial nerve dysfunction. [ 1 5 ] The concurrence of DAVFs and PAVFs is exceedingly rare, and there are only 11 reports of such cases occurring at the craniocervical junction or cervical region[ 9 11 ] and 4 such cases located at the thoracolumbar region. [ 3 6 8 10 ] Sato et al .…”