PMC6744779_01
MRI Imaging. (a) Sagital section T1 weighted MRI imaging shows the hypointense multilobulated mass from cervical 4-6 suggested artery venous malformation (red arrow). (b) Axial section T1 weighted MRI shows the feeding artery course in the foramen intervertebralis to the spinal canal and compressed the spinal cord at level C6 (red arrow). (c) MR angiography shows huge AVM from Cranio-cervical junction to C7 (red arrow).
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The craniocervical magnetic resonance imaging/magnetic resonance angiography/digital subtraction angiography revealed a large C1-C7 right-sided cervical spinal dural AVM; the main two feeders were coming from the C5-C6 and C6-C7 neural foramen [Figures 1 and 2].
Digital subtraction angiography shows the AVM with huge feeding artery (single red arrow) at level C5-6, 6-7 and draining vein to the marginal plexus nearby foramen magnum (double red arrow).
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The craniocervical magnetic resonance imaging/magnetic resonance angiography/digital subtraction angiography revealed a large C1-C7 right-sided cervical spinal dural AVM; the main two feeders were coming from the C5-C6 and C6-C7 neural foramen [Figures 1 and 2].
3D CT angiography. (a) A huge feeder courses into the canalis spinalis through the foramen intervertebralis(single red arrow), transverse foramen are empty from vertebral artery (two blue arrows), the aberrant vertebral artery courses outside transverse foramen (three black arrows). (b) Right aberrant vertebral artery (single red arrow) and normal left vertebral artery courses inside the transverse foramen (double blue arrows). (c) Right vertebral artery loop at the C1 to occipital bone just above the C1 transverse (single red arrow), Left vertebral artery courses normally from inside transverse foramen C1 to occipital bone to enter the intracranial portion (double black arrows). (d) 3D CT after doing hemilaminectomy in computer simulation shows a long thin AVM courses at C2-3 (single red arrows) and huge widen AVM at level C4-6 (double red arrows). (e) 3D CT in axial section at level foramen magnum and C1 shows AVM at C2-3 (single red arrow), and huge AVM at C4-6 is larger than in the level C2-3 (double red arrow).
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Three-dimensional computed tomography angiography further elucidated the location of the AVM and its feeders [Figure 3].
Patient position. (a) Prone position with head is holding by Mayfield head frame to fix the cervical spine in straight position. (b) Cervical x ray using C-arm to confirm cervical level. (c) Midline incision and dissecting the paraspinal muscles to expose the lamina from Occipital to C7. (d) Laminectomy was performed at C5-6 and exposed the AVM with very thin AVM wall. (e) Double permanent clips was done at huge main feeding artery at C4-5, 5-6 and resect the AVM to expose the dura and decompress cervical cord. (f) The lateral mass was placed at C5-6 bilaterally and tightened with cross link titanium plate. (g) The position of lateral mass at C5-6 and clip are confirmed using C-arm.
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This allowed for decompression and resection of the AVM and was followed by lateral screws/rod fusion [Figure 4].
Post-operative course. (a) 4 Days after surgery, she improved her upper extremities gradually. (b) 1 Month after surgery, she could stand up but still having difficulties in walking. (c) 2 Months after surgery, she could walk normally.
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Her quadriparesis continued to improve over 6 post operative days, and she was discharged on day 7. 2 months later, she was able to ambulate (e.g., Karnofsky Performance Status score 100) [Figure 5].