Intracranial subarachnoid hemorrhage resulting from cervical spine dural arteriovenous fistulas: literature review and case presentation

Abstract

<jats:p>Cervical dural arteriovenous fistulas (dAVFs) are a rare cause of intracranial subarachnoid hemorrhage (SAH) but should be considered when other sources are not found. Subarachnoid hemorrhage caused by dAVF is thought to occur as a result of venous hypertension in most cases. The clinical presentation, acute onset of severe headache, is similar to that in patients with other causes of SAH; however, severe neurological deficits (Hunt and Hess Grade IV and V SAH) have not been reported in SAH caused by cervical dAVFs. Patients with this type of SAH commonly report suboccipital headache, neck pain, and nausea, and thus these hemorrhages can be easily dismissed as perimesencephalic SAH. Vigilant evaluation with 4-vessel cerebral angiography, including selective catherization of both proximal vertebral arteries, should be performed. The practice of unilateral vertebral artery injection with reflux into the contralateral vertebral and posterior inferior cerebellar arteries has the potential to overlook cervical dAVF. Magnetic resonance imaging may be useful to evaluate for other causes of SAH but is probably not sensitive for the identification of a cervical dAVF. Surgical treatment of this lesion has an excellent outcome.</jats:p>

Angiographic Characteristics and Treatment of Cervical Spinal Dural Arteriovenous Shunts

“…17,18 Previous reports on the treatment of the cervical spinal DAVSs have predominantly focused on surgical ligation of the draining vein due to concerns of recanalization and the difficulty of selecting fine dural feeders. 3,4,6,8,9,19 In our experience, a combined multidisciplinary approach of treatment resulted in symptomatic improvement in 10 patients (83%) in this series. In 2 patients, angiographic cure was achieved with liquid embolic agents only.…”

“…16 The most important implication of this finding is the necessity to include the right vertebral artery-which may be omitted when the contralateral vertebral artery is dominant-especially in cases of hemorrhagic presentation. 6 Our protocol included bilateral vertebral arteries, especially in cases of hemorrhagic presentation; thus, none of the cases were missed on the initial DSA except for a patient who hemorrhaged from a radicular feeder from the right thyrocervical artery (case 10). Spinal angiography or high-resolution MR angiography should be performed in a patient with SAH and negative findings on cerebral angiography if the patient shows symptoms referable to the spinal cord.…”

“…7 However, previous reports have shown that cervical spinal DAVSs may be more frequently associated with hemorrhage. 3,4,6,[8][9][10] According to a review of the literature by Aviv et al, 4 approximately 45% of patients with cervical DAVSs presented with SAH as their initial symptom. However, many of these patients had DAVSs at the foramen magnum level (37%; 15 of 41 reviewed cases), which were not true cervical spinal DAVSs.…”

“…2 Literature regarding cervical spinal DAVSs is limited to a few case series. [3][4][5][6] The purpose of this study was to assess the clinical and angiographic characteristics of cervical spinal DAVSs from a large prospectively collected single-center data base.…”

Intramedullary hemorrhage from a thoracolumbar dural arteriovenous fistula

“…The low-flow and low-volume nature of these lesions makes hemorrhage very unlikely, but cases reporting subarachnoid and subdural hemorrhages do exist, albeit predominantly occurring intracranially [1] and within the cervical region. [2][3][4][5][6][7][8][9]. Intramedullary hemorrhage caused by thoracolumbar dural AVFs is exceedingly rare.…”