2025 Poster Presentations
P435: MANAGEMENT OF CRANIOCERVICAL JUNCTION ARTERIOVENOUS FISTULA FED BY THE RADICULAR AND SPINAL ARTERIES DRAINING INTO A COMMON INTRADURAL VEIN: A CASE REPORT
Satoshi Matsuo1; Kenta Hara1; Akifumi Yokomizo1; Noritaka Komune2; Osamu Akiyama3; Toru Hasegawa1; Hidenori Yoshida1; Kiyotaka Fujii1; 1Department of Neurosurgery, Fukuoka Tokushukai Hospital; 2Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; 3Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan
Introduction: Arteriovenous fistulas at the craniocervical junction (CCJ AVF) are rare vascular malformations, accounting for less than 2% of patients with intracranial or spinal AVFs; their most common presentation is subarachnoid hemorrhage.1-3 Though a precise understanding of the angioarchitecture of CCJ AVF is essential for appropriate treatment and achieving curative treatment, preoperative definitive diagnosis can be difficult due to its complexity, and intraoperative findings may provide clues to the definitive diagnosis. Here, we report a case of a radicular CCJ AVF fed by the radicular and spinal arteries draining into a common intradural vein, which was finally diagnosed based on intraoperative findings and treated by disconnecting the common draining vein.
Case presentation: A 57-year-old male presented with sudden cervical pain due to a subarachnoid hemorrhage, predominantly in the posterior cranial fossa. Neuroradiological examination revealed an AVF at the CCJ with the right C2 radicular and spinal pial arteries branching from the anterior spinal artery (ASA) as feeders, which drained into the anterior spinal vein via a single intradural vein. Fusion images of computed tomography angiography and magnetic resonance cisternography revealed that the fistula was located along the anterior root of the C2 nerve. Since the preoperative images could not identify the exact shunt point of the feeder from the spinal pial arteries branching from the ASA, a preoperative diagnosis of radicular AVF, concurrent dural and perimedullary AVF, and dural AVF with a pial feeder was made. Direct surgery was planned because the AVF was fed by the ASA branch and endovascular treatment was considered to increase the risk of spinal infarction. Small right suboccipital craniotomy, C1 laminectomy, and partial C2 laminectomy were performed. During surgery, an AVF was detected in the C2 anterior roots, as shown in the preoperative neuroradiological findings. Therefore, we made a diagnosis of radicular AVF rather than dural or perimedullary AVF. A common single drainer was disconnected surgically, and the disappearance of the shunt flow was confirmed using intraoperative digital subtraction angiography and indocyanine green video angiography. The postoperative course was uneventful, and the patient’s condition returned to normal.
Discussion: This case indicates that a CCJ AVF with multiple feeders draining into a common intradural draining vein can be successfully treated by disconnecting the vein. CCJ AVFs often exhibit complex angioarchitecture. Understanding the angioarchitecture of the lesion using various modalities and planning appropriate treatment strategies are essential for their treatment.
References:
1. Hiramatsu, Masafumi, et al. "Angioarchitecture of arteriovenous fistulas at the craniocervical junction: a multicenter cohort study of 54 patients." Journal of neurosurgery 128.6 (2017): 1839-1849.
2. Song, Zihao, et al. "Arteriovenous fistulas in the craniocervical junction region: with vs. without spinal arterial feeders." Frontiers in Surgery 9 (2023): 1076549.
3. Ma, Yongjie, et al. "Clinical features, treatment strategies and outcomes of craniocervical junction arteriovenous fistulas: a cohort study of 193 patients." Stroke and Vascular Neurology 9.1 (2024).
