•Most spinal dural AVFs occur in males (31-74yr) at the thoracolumbar region. Intracranial foramen magnum spinal dural AVFs with perimedullary venous drainage are rare. They are most commonly supplied by the external carotid, occipital and meningeal branches of the vertebral artery (63% from the right VA). The clinical presentation ranges from SAH (34-45% cases) to progressive myelopathy (50% cases) secondary to venous congestion and spinal cord ischemia. The acute development of symptoms, together with imaging, led us to believe that there was a possible hemorrhage with underlying edema/ischemia of the cervical cord.
• Cervical and Thoracic MRI demonstrated a dilation of the perimedullary venous plexus. Diagnostic angiography revealed an AV fistula at the V4 segment of the right vertebral artery. Endovascular embolization was unsuccessful, therefore, the patient underwent a far lateral supracondylar approach for clip ligation. A fistula was identified intraoperatively and confirmed pre and post ligation with indocyanine green video (ICG) angiography (fig1-3).
•Treatment options includes endovascular embolization, clip ligation or a combination. Surgical ligation may be preferred secondary to numerous FM meningeal anastomosis, small target vessel caliber, risk of embolic agent reflux and fistula recanalization. Treatment modality and surgical approach should be individualized to patient pathology and surgeon/interventionalist familiarity.
•Guo LM, Zhou HY, Xu JW, Wang GS, Tian X, Wang Y, Qiu YM, Jiang JY. Dural arteriovenous fistula at the foramen magnum presenting with subarachnoid hemorrhage: case reports and literature review. Eur J Neurol. 2010 May;17(5):684-91. doi: 10.1111/j.1468-1331.2009.02895.x. Epub 2009 Dec 29.
•Ryo H, Terumasa K, Kazuhiko N, Toshihiko K. Foramen Magnum Dural Arteriovenous Fistula Treated by a Microsurgical Technique Combined with a Feeder Occlusion Using Transarterial Coil Embolization. Turk Neurosurg 2015, Vol: 25, No: 6, 971-975.
•Asakawa H, Yanaka K, Fujita K, Marushima A, Anno I, Nose T. Intracranial dural arteriovenous fistula showing diffuse MR en- hancement of the spinal cord: Case report and review of the literature. Surg Neurol 2002;58:251–7.
•Lee J, Cho Y, Kwon B, Han M. Dural Arteriovenous Fistula at the Foramen Magnum with Holocord Myelopathy: Case Report. Neurointervention 2010;5:53-57.
Continue the discussion on LinkedIn with our members-only Case of the Month Discussion Group
. Create a dialogue and see how your recommendations compare with your colleagues across the globe.