Craniocervical arteriovenous fistula

Case contributed by Dr Andrei Tsoriev

Presentation

Female patient 59 y.o., slowly progressive central spastic tetraparesis, one week before MRI bulbar symptoms appeared with dysphagia, dysarthria. No previous trauma reported.

Patient Data

Age: 59
Gender: Female

MRI

Modality: MRI

Magnetic resonance imaging before and after contrast media injection, using T1-, T2-, T2*-weighted, FLAIR, DWI with ADC sequences.

Modality: DSA (angiography)

Selected projections from 4 vessel neuro DSA.

There is an arteriovenous fistula with filling and enlargement of superficial veins around brainstem and spinal cord from the branch of medial meningeal artery, branch of external carotid artery.

Case Discussion

Dural arteriovenous fistula (DAVF) is mostly acquired vascular lesion, either spontaneous, as in this case, or traumatic in origin. Dural arteriovenous fistulae at the craniocervical junction are very unusual, especially spontaneous ones without history of previous recent or old trauma.

Symptoms of DAVF of such localisation may vary:

  • most frequent course is gradually developing neurologic focal deficit depending on localisation, with is related to venous congestion and subsequent development of subacute necrotising encephalomyelopathy (Merland et al, 1980 and Hassler et al, 1989)
  • sometimes, when patient has cranial AVF he or she meat develop intracranial hypertension signs
  • radiculopathy
  • cranial nervу palsies
  • subarachnoid haemorrhage is also a complication of DAVF, may be seen in approximately 45% cases (Kinouchi et al, 1998)
  • occipitalgia (Chiba et al, 1994)
  • transient ischemic attack (Masuo et al, 1999)

Median age of presentation of cervical DAVFs is believed to be 58 years (Aviv et al, 2004) and there is male predominance from 2:1 to 3:1 (Symon et al, 1984).

Magnetic resonance imaging is strongly indicated in cases of upper cervical myelopathy, either alone or with bulbar symptoms. Visual signs of oedema of involved segments of spinal cord and brainstem, high ADC, indicating vasogenic edema and excluding ischemic lesion, absence of contrast enhancement, excluding mass-lesions, enlarged and tortuous subarachnoid vessels are strongly indicative of DAVF and selective DSA should be performed to confirm DAVF and consider its percutaneous embolisation. 

 

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Case Information

rID: 33636
Case created: 19th Jan 2015
Last edited: 25th Apr 2017
Inclusion in quiz mode: Included

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