PMC8769398_01
Preoperative MR images and CTA image. (a) T2 on sagittal view, (b) T2 on axial at C2/3, (c) T2 on axial at C3/4, (d) Gd-enhanced T1 on sagittal view, and (e) 3D construction image (red: artery, blue: vein). CTA: computed tomographic angiography, Gd: gadolinium, MR: magnetic resonance, 3D: three-dimensional.
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F1
On magnetic resonance imaging (MRI), an epidural mass was recognized located around the right foramen of the C2-C4 compressing the spinal cord to the left (Fig. 1a-1c). A part of the mass lesion was enhanced using contrast enhancement (Fig. 1d). 3D-computed tomography angiography indicated extradural AVFs on the right in the cervical spine with multi-feeders (Fig. 1e).
Angiogram. (a) Right subclavian angiogram, (b) right VA angiogram, and (c) left VA angiogram.
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F2
The right subclavian artery angiogram demonstrated a high flow arteriovenous shunts at the extradural space around the right foramen of C3/4 from multi-branches of the ascending cervical artery (ACA) which consisted the main portion of the AVF (Fig. 2a). Right vertebral artery (VA) angiogram demonstrated arteriovenous shunts at the extradural space around the right foramen of C3/4 from radicular artery of V1 portion (Fig. 2b). Left VA angiogram demonstrated arteriovenous shunts at the extradural space around the right foramen of C2/3 and C3/4 from radicular artery of V1 portion (Fig. 2c).
Cone beam CT image with right and left VA angiogram showed the direct reflux to extradural vertebral venous plexus. (a) Axial image with right VA angiogram at C2 level, (b) axial image with left VA angiogram at C3 level, (c) axial image with right VA angiogram at C2 level, (d) axial image with right VA angiogram at C3 level, and (e) coronal image with right VA angiogram. CT: computed tomography, VA: vertebral artery.
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F3
Cone beam CT images more clearly suggested that it was extradural AVF (Fig. 3).
Cone beam CT image demonstrated that the microcatheter was inserted into extradural space at C4 body level via hypoglossal canal. White ring: hypoglossal canal. (a-d) Coronal image, (e, f) sagittal image. CT: computed tomography.
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F4
The microcatheter (Excelsior 1018; Stryker, Fremont, CA, USA) was coaxially inserted into extradural space at C3/4 on the right side nearby the shunting point via anterior condylar emissary vein in the hypoglossal canal and coil embolization was performed (Fig. 4).
Final angiogram. (a) Right subclavian angiogram. Arteriovenous shunts were obliterated. (b, c) Bilateral VA angiogram at the same time. Arteriovenous shunts were obliterated. VA: vertebral artery.
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F5
The combination of transvenous and transarterial embolization leaded complete arteriovenous shunts obliteration (Fig. 5).