Successful balloon-assisted coil embolization for a diagnostically difficult case of spontaneous vertebrovertebral arteriovenous fistula

Abstract

Background: We describe a rare case of idiopathic lower cervical vertebro-vertebral arteriovenous fistula (VVAVF) with compression of the nerve roots and spinal cord, successfully treated with detachable coils utilizing the transarterial balloon-assisted technique without complication of coil mass.

Case description: A 68-year-old woman was admitted for numbness of the left upper limb and pain in the left neck. Cervical magnetic resonance imaging (MRI) revealed compression of nerve roots and spinal cord by a large vascular lesion. The left vertebral angiography demonstrated a VVAVF draining into the vertebral venous plexus at C5 level. Under general anesthesia, the fistula site was accessed with a microcatheter through the right femoral artery, and successful embolization performed by compactly placing several detachable coils using balloon-assisted technique. The patient made a full recovery, with long-term MRI-documented left vertebral artery patency and no fistular leakage, and without postoperative complications.

Conclusion: Target occlusion utilizing the balloon-assisted technique in this case of VVAVF with compression of nerve roots and spinal cord, was effective in improving neurological symptoms, and achieved long-term occlusion when preservation of the VA was desired.

Keywords: Balloon-assisted technique; Cervical portion of vertebral artery; Endovascular embolization; Radiculopathy; Vertebro-vertebral arteriovenous fistula.

Figure 1:

Preoperative MR image. T2-weighted axial (a) and coronal (b) images demonstrated enlarged flow voids of the left anterior internal vertebral venous plexus (arrowheads) at C4 and C3-6. Severe compression of the nerve root and spinal cord from the enlarged epidural venous plexus is also demonstrated. The maximum intensity projection of time-of-flight images demonstrated anterior internal vertebral venous plexus at arterial phase at C2 (c) and C5 (d). The neck MR angiography showed abnormal veins around left vertebral artery (e and f).

Figure 2:

Preoperative and postoperative digital subtraction angiography image. Anteroposterior (AP) view (a) and lateral (b) view of the left vertebral artery (VA) angiography, and oblique view (c) of reconstructed three-dimensional rotational angiography of the left VA demonstrated high-flow vertebro-vertebral arteriovenous fistula (VVAVF) between V2 segment (arrowheads) and dilated vertebral venous plexus. AP view (d) and lateral (e) view of angiogram showed that the coils (arrows) were placed in the left vertebral venous plexus just distal to the shunt, using a microballoon catheter (small arrow). The AP view (f) and lateral view (g) of the left VA angiography obtained immediately after coil embolization demonstrated the disappearance of the VVAVF.

Figure 3:

Postoperative MR image. The T2-weighted axial (a) and coronal (b) images 4 years after embolization showed reduction of flow voids of the left anterior internal vertebral venous plexus (arrowhead) at C4, and improvement of compression of nerve roots and spinal cord. The MIP images demonstrated no recurrence of the fistula at C2 (c) and C5 (d). The neck MR angiography obtained 4 years later demonstrated that the fistula was completely occluded (e).