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CC BY-NC-ND 4.0 · Asian J Neurosurg 2019; 14(04): 1256-1267
DOI: 10.4103/ajns.AJNS_259_19
Case Report

Medullary hemorrhage caused by foramen magnum dural arteriovenous fistula successfully obliterated using combination of endovascular and surgical treatments: A case report and literature review

Prasert Iampreechakul
0   Department of Neurosurgery, Prasat Neurological Institute, Bangkok
,
Anusak Liengudom
0   Department of Neurosurgery, Prasat Neurological Institute, Bangkok
,
Punjama Lertbutsayanukul
1   Department of Neuroradiology, Prasat Neurological Institute, Bangkok
,
Yodkhwan Wattanasen
1   Department of Neuroradiology, Prasat Neurological Institute, Bangkok
,
Somkiet Siriwimonmas
2   Department of Radiology, Bumrungrad International Hospital, Bangkok
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The authors describe an extremely rare case of foramen magnum dural arteriovenous fistula (DAVF), Cognard type V, presented with medullary hemorrhage caused by venous varix on the lateral medullary draining vein embedded into the medulla oblongata. Following mild myelopathy for 3 days, a 20-year-old male developed dyspnea, generalized seizures, loss of consciousness, and finally cardiac arrest. After successful resuscitation, computed tomography scan (CT) of the brain was obtained and showed acute medullary hemorrhage. Subsequent magnetic resonance imaging of the brain revealed diffuse venous congestion or edema of the medulla with multiple dilated flow voids surrounding the medulla, more prominent on the left side, with venous varix embedded into the left-sided of the lower medulla. He was sent to the emergency department of the local hospital and intubated promptly. A few minutes later, the patient had a cardiac arrest. Digital subtraction angiography (DSA) demonstrated DAVF of the foramen magnum supplied mainly by dural branches of bilateral hypertrophic posterior inferior cerebellar arteries (PICAs), slightly by the posterior meningeal branch of the left vertebral artery, and the jugular branch of the left ascending pharyngeal artery (APA) originating from the occipital artery. Transarterial embolization through the bilateral dural branches of the PICAs was successfully performed using N-butyl-2-cyanoacrylate (NBCA), resulting in complete obliteration. The patient had excellence recovery and lost to annual follow-up. Seven years later, he had a recurrent of the fistula presented with occipital headache. DSA with angiographic CT in three-dimensional reconstruction and maximum intensity projection reformatted images clearly demonstrated the exact location of the DAVFs at the posterior rim of the foramen magnum, mainly recruited by the hypertrophic jugular branch of the APA originating from the occipital artery. The fistula was successfully treated surgically following transarterial embolization through the jugular branch of the APA using NBCA. Follow-up DSA confirmed complete obliteration of the DAVF. The patient has remained clinically asymptomatic 2 years after the operation.

Key-words:

Brainstem congestion - dural arteriovenous fistula - foramen magnum - medullary hemorrhage - pial supply - venous varix

Financial support and sponsorship

Nil.




Publication History

Article published online:
09 September 2022

© 2019. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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