Transarterial embolization of a cervical dural arteriovenous fistula. Presenting with subarachnoid hemorrhage

Abstract

We describe a case of a 75-year-old man who presented with acute onset of headache and subarachnoid hemorrhage and initial cerebral angiography was deemed "negative". In retrospect, a faint contrast collection was present adjacent to the right vertebral artery at the C1 level suspicious for a small dural arteriovenous fistula (dAVF). Follow-up angiography with selective microcatheter injections of the right vertebral artery and C1 radicular artery confirmed a complex dAVF with characteristically specific venous drainage patterns associated with a subarachnoid hemorrhage presentation. Subsequently, the cervical dAVF was treated with superselective glue embolization resulting in complete occlusion. Cervical dAVFs are extremely rare vascular causes of subarachnoid hemorrhage. Both diagnostic angiography and endovascular treatment of these lesions can be challenging, especially in an emergent setting, requiring selective evaluation of bilateral vertebral arteries and careful attention to their cervical segments. Although only a single prior case of a cervical dAVF presenting with subarachnoid hemorrhage has been successfully treated with embolization, modern selective transarterial techniques may allow easier detection and treatment of subtle pathologic arteriovenous connections.

Figure 1

Axial CT head image shows subarachnoid blood (arrowheads) predominantly at the foramen magnum and upper cervical spinal canal.

Figure 2

Lateral digital subtraction angiography (DSA) image of the right vertebral artery identifies suspicious area of subtle contrast puddling (arrow) adjacent to the right vertebral artery at the level of the C1 arch.

Figure 3

Anteroposterior DSA image of the distal right vertebral artery through a selective microcatheter injection demonstrates the C1 radicular branch (arrow) supplying the fistula as well as faint early opacification of the perivertebral venous plexus (arrowhead).

Figure 4

Magnified anteroposterior (A) and lateral (B) DSA images of the C1 radicular branch through a superselective microcatheter injection delineates the exact location of the arteriovenoous fistula (arrowheads), ascending intracranial venous drainage (black arrows), and prominent cervical epidural venous plexus with small associated venous varix or aneurysms (white arrows).

Figure 5

Magnified lateral DSA image of the right vertebral artery after embolization demonstrates complete occlusion of the fistula and no evidence of early opacification of the perivertebral epidural venous plexus or ascending perimedullary venous drainage.