Microsurgical Obliteration of Craniocervical Junction Dural Arteriovenous Fistulas: Multicenter Experience

Mohamed M. Salem, Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
Visish M. Srinivasan, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Daniel A. Tonetti, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.
Krishnan Ravindran, Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA.
Philipp Taussky, Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
Kaiyun Yang, Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA.
Katherine Karahalios, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.Follow
Kunal P. Raygor, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.
Ryan M. Naylor, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.
Joshua S. Catapano, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.Follow
Samon Tavakoli-Sabour, Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
Ahmed Abdelsalam, Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
Stephanie H. Chen, Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
Ramesh Grandhi, Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
Brian T. Jankowitz, Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
Mustafa K. Baskaya, Department of Neurosurgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
Justin R. Mascitelli, Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas, USA.
Jamie J. Van Gompel, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.
Jacob Cherian, Department of Neurosurgery, University of Maryland, Baltimore, Maryland, USA.
William T. Couldwell, Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
Louis J. Kim, Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
Aaron A. Cohen-Gadol, Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.
Robert M. Starke, Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
Peter Kan, Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA.
Amir R. Dehdashti, Department of Neurosurgery, North Shore University Hospital, Northwell Health, Manhasset, New York, USA.
Adib A. Abla, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.
Michael T. Lawton, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.Follow
Jan-Karl Burkhardt, Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.

Document Type

Article

Abstract

BACKGROUND: Dural arteriovenous fistulas (dAVFs) located at craniocervical junction are extremely rare (1%-2% of intracranial/spinal dAVFs). Their angio-architectural complexity renders endovascular embolization to be challenging given multiple small feeders with risk of embolysate reflux into vertebral artery and limited transvenous access. The available literature discussing microsurgery for these lesions is limited to few case reports. OBJECTIVE: To report a multicenter experience assessing microsurgery safety/efficacy. METHODS: Prospectively maintained registries at 13 North American centers were queried to identify craniocervical junction dAVFs treated with microsurgery (2006-2021). RESULTS: Thirty-eight patients (median age 59.5 years, 44.7% female patients) were included. The most common presentation was subarachnoid/intracranial hemorrhage (47.4%) and myelopathy (36.8%) (92.1% of lesions Cognard type III-V). Direct meningeal branches from V3/4 vertebral artery segments supplied 84.2% of lesions. All lesions failed (n = 5, 13.2%) or were deemed inaccessible/unsafe to endovascular treatment. Far lateral craniotomy was the most used approach (94.7%). Intraoperative angiogram was performed in 39.5% of the cases, with angiographic cure in 94.7% of cases (median imaging follow-up of 9.2 months) and retreatment rate of 5.3%. Favorable last follow-up modified Rankin Scale of 0 to 2 was recorded in 81.6% of the patients with procedural complications of 2.6%. CONCLUSION: Craniocervical dAVFs represent rare entity of lesions presenting most commonly with hemorrhage or myelopathy because of venous congestion. Microsurgery using a far lateral approach provides robust exposure and visualization for these lesions and allows obliteration of the arterialized draining vein intradurally as close as possible to the fistula point. This approach was associated with a high rate of angiographic cure and favorable clinical outcomes.

Medical Subject Headings

Humans; Female; Middle Aged; Male; Central Nervous System Vascular Malformations (diagnostic imaging, surgery, complications); Spinal Cord Diseases (surgery); Embolization, Therapeutic (methods); Vertebral Artery (diagnostic imaging, surgery, pathology); Subarachnoid Hemorrhage (complications)

Publication Date

1-1-2023

Publication Title

Neurosurgery

E-ISSN

1524-4040

Volume

92

Issue

1

First Page

205

Last Page

212

PubMed ID

36519864

Digital Object Identifier (DOI)

10.1227/neu.0000000000002196

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