Subarachnoid Hemorrhage with Concurrent Dural and Perimedullary Arteriovenous Fistulas at Craniocervical Junction: Case Report and Literature Review

• Published in: World neurosurgery 2019-07, Vol.127, p.331-334
• Main Authors: Sato, Hirotaka, Wada, Hajime, Noro, Shohei, Saga, Takehiro, Kamada, Kyousuke
• Format: Article
• Language: English
• Subjects: Aged; Central Nervous System Vascular Malformations - complications; Central Nervous System Vascular Malformations - diagnostic imaging; Central Nervous System Vascular Malformations - surgery; Cervical Vertebrae - diagnostic imaging; Cervical Vertebrae - surgery; Craniocervical junction; dAVF; Humans; Male; Medulla Oblongata - diagnostic imaging; Medulla Oblongata - surgery; Perimedullary AVF; Skull Base - diagnostic imaging; Skull Base - surgery; Subarachnoid Hemorrhage - complications; Subarachnoid Hemorrhage - diagnostic imaging; Subarachnoid Hemorrhage - surgery
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2019.02.079

The association between a dural arteriovenous fistula (dAVF) and perimedullary arteriovenous fistula (AVF) is rarely observed at the craniocervical junction (CCJ). We present a case of subarachnoid hemorrhage (SAH) with concurrent dAVF and perimedullary AVF at the CCJ. Here, we describe the cause of bleeding and the process of determining whether it was a varix or an arterial aneurysm. A 69-year-old man with SAH visited the emergency department. A dAVF at the CCJ was detected on digital subtraction angiography (DSA). However, after 3 weeks, when the DSA was repeated, a perimedullary AVF and varix were identified. We performed an endovascular treatment, but because the perimedullary AVF remained, we performed a direct surgery. The patient was discharged without weakness, but this left abducens nerve palsy remained. In recent reports, SAH caused by concurrent dAVF and perimedullary AVF raised the possibility of an arterial aneurysm. However, in this case, the possibility of venous bleeding was high and a varix rather than an aneurysm was observed. On the basis of the reported cases, concurrent dAVF and perimedullary AVF at the CCJ is a "middle-flow arteriovenous shunt" that may induce a varix or an arterial aneurysm.