PMC10151492_01
Perioperative neuroimages of Case 12. A cervical spine MRI showed an expanded spinal brain stem and a longitudinal extensive cervical cord enlargement with obvious edema, and vascular flow voids was also demonstrated in front of the cervical cord (A). The cerebral DSA demonstrated a DAVF located at the foramen magnum supplied by the meningeal branch of left VA, and the fistula was draining through the bridge-medullary veins into the dilated tortuous anterior spinal vein (B), lateral view; (C), anteroposterior view; (D), oblique view with magnification. (E) showed the incision line and the operation position (park bench position). F demonstrated a large tortuous vein was visible at the level of the foramen magnum, and it originated near the dural penetration of the left vertebral artery and formed a "C" pattern crawling between the vertebral artery and the medulla. (F) showed an aneurysm min-clip was temporarily applied to the origin of the fistula to occlude the shunt. Intraoperative DSA revealed the complete disappearance of the DAVF (G). After electrical coagulation and disconnection of the fistula at its origin from the dura, repeat cerebral DSA confirmed the complete obliteration of the fistula (H).
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F1
Vascular flow voids were also demonstrated in front of the cervical cord (Figure 1A). A complete spine DSA was negative, while the cerebral DSA demonstrated a DAVF located at the foramen magnum supplied by the meningeal branch of the left VA (Figures 1B-D). The fistula was draining through the bridge-medullary veins into the dilated tortuous anterior spinal vein (SPV) (Figures 1B-D; Supplementary material Video 1). With the patient in the park bench position on his right side, the foramen magnum was osteoclastically enlarged, followed by a partial hemilaminectomy of C1(Figure 1E; Supplementary material Video 2). It originated near the dural penetration of the left vertebral artery and formed a "C" pattern crawling between the vertebral artery and the medulla (Figure 1F). After an aneurysm min-clip was temporarily applied to the origin of the fistula (Figure 1F), intra-operative DSA was performed and revealed the complete disappearance of the DAVF (Figure 1G; Supplementary material Video 3). After the operation, a repeated cerebral DSA confirmed the complete obliteration of the fistula (Figure 1H; Supplementary material Video 4).
PMC10151492_02
Perioperative neuroimages of Case 13. Emergent cranial CT revealed diffuse SAH and 4th ventricular hematoma (A). Emergent cerebral DSA revealed a DAVF located at the foramen magnum supplied by the meningeal branch of the right VA, draining into the enlarged tortuous medullary vein (B). During the procedure, the microcatheter tip was advanced to reach the optimal position (C); the injection of Onyx was continued until the DAVF was completely obliterated (D). Follow-up angiography at 6 months did not reveal any fistula residual or recurrence (E), lateral view; (F), anteroposterior view.
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F2
Emergent cranial CT revealed diffuse SAH and 4th ventricular hematoma (Figure 2A) (Fisher grade IV). Emergent complete cerebral DSA revealed a DAVF located at the foramen magnum supplied by the meningeal branch of the right VA, draining into the enlarged tortuous medullary vein (Figure 2B). Once the microcatheter tip was advanced to reach the optimal position (Figure 2C), the injection of Onyx-18 (MTI-EV3) was carried out. Whenever any venous migration appeared, the injection was stopped to allow for solidification and subsequently the injection was continued until the DAVF was completely obliterated (Figure 2D). Follow-up angiography at 6 months did not reveal any fistula residual or recurrence (Figures 2E, F).