Endovascular embolization combined with anterior cervical corpectomy for treatment of cervical spinal dural arteriovenous fistula

Abstract

Background: The two main treatments for spinal dural arteriovenous fistula (SDAVF) include microsurgical occlusion or endovascular embolization (i.e., the latter alone has high recurrence rates). Here, we combined both strategies to treat/obliterate a cervical SDAVF more effectively.

Case description: A 34-year-old male presented with a marked decline in mental status attributed to an infratentorial subarachnoid hemorrhage. The left vertebral angiogram revealed a ruptured, low cervical SDAVF. He underwent successful occlusion of the spinal fistula utilizing super selective catheterization and endovascular embolization (i.e., utilizing Onyx-18 for the obliteration of target arteries). Due to significant SDAVF accompanying vessel recruitment/complex angioarchitecture, we additionally performed a C5 anterior corpectomy/fusion to afford direct access and complete surgical SDAVF occlusion. Three and 6 months later, repeated angiograms confirmed no recurrent or residual SDAVF.

Conclusion: We successfully treated a low cervical SDAVF using a combination of endovascular embolization and direct surgical occlusion through an anterior C5 corpectomy with a fusion approach.

Keywords: Anterior cervical approach; Corpectomy; Endovascular embolization; Hybrid strategy; Spinal dural arteriovenous fistula.

Figure 1:

Axial plane of non-contrast cranial computed tomography scan on admission. The study revealed the presence of infratentorial subarachnoid hemorrhage, as well as ventricular irruption, with evidence of bleeding in the fourth ventricle.

Figure 2:

Lateral view of left vertebral artery angiogram. The study revealed an arteriovenous shunt (black asterisk) inside the cervical canal, fed by the left C6 radicular artery (red arrow) and with retrograde venous drainage through the anterior cervical venous plexus (blue arrow).

Figure 3:

Anteroposterior view of embolization of the left C6 radicular artery. After successfully occluding the target artery with Onyx-18, we evidenced continuous arterial flow from the right C5 radicular artery (red arrow).

Figure 4:

Super selective catheterization of the right C5 radicular artery. (a) shows the balloon (black arrow) at the V2 segment of the right vertebral artery and the microcatheter placed in the target artery (red arrow); casts of Onyx-18 are seen (red asterisks). (b) right vertebral artery angiogram confirmed obliteration of the fistula.

Figure 5:

Direct occlusion of the low cervical, ventral, spinal dural fistula. (a) shows anterior cervical approach, and (b) shows the C5 corpectomy. In postoperative anteroposterior (c) and lateral (d) X-ray views, the interbody spacer and the anterior lordotic plate are seen.