Dural arteriovenous fistula Type V

Case contributed by Yves Leonard Voss

Presentation

Progressive hypesthesia and paresis of the lower extremities over the last 3 weeks.

Patient Data

Age: 30 years
Gender: Male

MRI

MRI

FLAIR: Focal myelopathy of the medulla oblongata

TOF: Enlarged left sided bernasconi artery, round vascular structure close to the left petrous bone

T1+C: Dilated tortuous perimedullary veins

DWI: Facilitated diffusion (thus its edema not ischemia)

SWI: No signs of hemorrhage

CT Angiogram

CT

Dilated and tortuous perimedullary veins.

DSA and Embolization

DSA (angiography)

A Cathether angiogram was performed injectiong the VA, ICA, ECA, subclavian artery, ascending cervical artery bilaterally.

dAVF supplied exclusively by the left tentorial artery originating from the left ICA.

Key images of endovascular treatment and axial CT in bone window demonstrating the localization of the embolized vasculature are shown.

Case Discussion

There is focal myelopathy of the medulla oblongata with cloudy medullary contrast enhancement and enlarged tortuous perimedullary veins.

The cause of this symptomatic high cervical myelopathy was a dural arteriovenous fistula (short 'dAVF'). In the Cognard/Merland/Djindjian classification of dAVFs this represents a textbook case of a type V fistula, which means it is an intracranial fistula with exclusively spinal perimedullary venous drainage.

In this case, the dAVF was supplied by the tentorial artery (Bernasconi/Cassinari) exclusively, which renders the angiographic images well arranged, which is not the case in many dAVF patients where several supplying arteries are usually present. In this exact case, the point of the arteriovenous fistula is identified close to the left petrous bone in TOF angiogram, where a round structure marks the beginning of the venous drainage. In the post contrast MRI and CT-A dilated tortuous perimedullary veins are seen, which is usually the best clue a dAVF is present. 

Endovascular treatment was performed. This patient was treated by transarterial embolization via the bernasconi artery. This artery is difficult to catheterize with a microcatheter, but a selective catheterization could be achieved using a balloon in the distal ICA as hypomochlion, and a wedge flow position could be established. Diluted histoacryl was used as an embolic agent. The embolization was successful because it reached the point of arteriovenous fistula and occluded the origin of the draining vein. 

The patient showed quick symptom relief within a few days of treatment.

MRI and CT imaging courtesy of Dr. Asmus Wulff (Christliches Krankenhaus Quakenbrück, Germany), angiogram and endovascular treatment imaging courtesy of Prof. R. Chapot and PD Dr. P. Mosimann (Alfried Krupp Krankenhaus Essen, Germany). 

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