Iampreechakul Prasert, Liengudom Anusak, Lertbutsayanukul Punjama, Wattanasen Yodkhwan, Siriwimonmas Somkiet
Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand.
Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand.
Asian J Neurosurg. 2019 Nov 25;14(4):1256-1267. doi: 10.4103/ajns.AJNS_259_19. eCollection 2019 Oct-Dec.
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.
作者描述了一例极为罕见的枕骨大孔区硬脑膜动静脉瘘（DAVF），Cognard V型，表现为嵌入延髓的外侧延髓引流静脉的静脉瘤导致的延髓出血。一名20岁男性在出现轻度脊髓病3天后，出现呼吸困难、全身性癫痫发作、意识丧失，最终心脏骤停。成功复苏后，进行了脑部计算机断层扫描（CT），显示为急性延髓出血。随后的脑部磁共振成像显示延髓弥漫性静脉充血或水肿，延髓周围有多个扩张的流空信号，左侧更明显，左侧延髓下部有静脉瘤嵌入。他被送往当地医院急诊科并立即插管。几分钟后，患者心脏骤停。数字减影血管造影（DSA）显示枕骨大孔区DAVF主要由双侧肥厚的小脑后下动脉（PICA）的硬脑膜分支供血，左侧椎动脉的脑膜后支略有供血，以及起源于枕动脉的左侧咽升动脉（APA）的颈静脉支供血。使用N-丁基-2-氰基丙烯酸酯（NBCA）成功地通过PICA的双侧硬脑膜分支进行了经动脉栓塞，导致完全闭塞。患者恢复良好，未进行年度随访。7年后，他因枕部头痛出现瘘复发。带有血管造影CT三维重建和最大强度投影重建图像的DSA清楚地显示了DAVF在枕骨大孔后缘的确切位置，主要由起源于枕动脉的APA肥厚的颈静脉支供血。通过使用NBCA经APA的颈静脉支进行经动脉栓塞后，瘘成功地接受了手术治疗。随访DSA证实DAVF完全闭塞。术后2年患者一直无临床症状。
