Technical note
Endovascular treatment for dural arteriovenous fistula at the foramen magnum: Report of five consecutive patients and experience with balloon-augmented transarterial Onyx injection

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Summary

Background

Foramen magnum dural arteriovenous fistulas (DAVF) with perimedullary venous drainage represent a small minority of intracranial DAVF, and only a number of small series with limited cases have been reported. The purpose of this retrospective study is to summarize experience of transarterial Onyx embolisation in the treatment of these lesions, with emphasis on the balloon-augmented technique.

Methods

Five consecutive patients with DAVF at the foramen magnum were treated by transarterial embolisation using the Onyx system. Their symptoms included myelopathy (n = 4) and SAH (n = 1). Suppliers were from the vertebral artery (VA) (n = 4), occipital artery (OA) (n = 4), and ascending pharyngeal artery (APA) (n = 2), with drainage to the perimedullary veins. After catheterization of the dilated supplier, the fistulous connections, proximal draining veins and appropriate distal segment of the feeders of these DAVF were transarterial embolized using Onyx-18. In three patients, balloon-augmented technique was used to assist embolisation. The technical feasibility of the procedure, angiographic results, and clinical outcome were evaluated.

Results

In every case, complete obliteration was achieved. Neither intraprocedural vessel rupture nor other procedure-related complications occurred. The results remained stable in all patients on follow-up angiograms (mean, 7.2 months). At the last clinical follow-up (mean, 17.6 months), two patients showed complete resolution of the initial symptoms, and three patients showed significant improvement.

Conclusion

We found that Onyx embolisation is a feasible and safe alternative to open surgery in the treatment of selective DAVF at the foramen magnum. The balloon-augmented technique widens indications for transarterial Onyx packing of these lesions, and improved safety of the procedure.

Section snippets

Patients and general information

From 2007–2011, consecutive five patients (four men, one women; age range, 36–61 years; mean age, 50.2 years) with foramen magnum DAVF were treated endovascularly at our institution. Informed consent from the patients and institutional review board approval were obtained. Clinical data on the patients are summarized in Table 1. Their symptoms included myelopathy (n = 4) and SAH (n = 1). All patients underwent complete cervicocerebral angiography. Suppliers were from the VA in four patients; OA, in

Results

The results and follow-up findings are summarized in Table 1. Complete angiographic obliteration was achieved in all five patients, in a total of five sessions. Balloon-augmented Onyx injection technique was used in three sessions (patient 2, 4, 5). In patient 2 and patient 5, the balloon was placed into the OA; in patient 4, it was placed into the neuromeningeal trunk of the APA.

Neither intraprocedural vessel rupture nor other procedure-related complications occurred. No new transient or

Patient 5

A 49-year-old woman presented with a 3-month history of progressive tetraparesis. On admission, physical examination revealed motor disturbances upper and lower extremities, right greater than left. The Babinski's response was positive bilaterally. MRI scan demonstrated abnormal vascular structures at the level of the foramen magnum. Angiography showed a DAVF at the foramen magnum. It was fed by the meningeal branches of right OA and VA, and the hypoglossal branch of APA, and drained to a

Discussion

Foramen magnum DAVF with perimedullary venous drainage (Type V) represent a small minority of DAVF, and only a number of small series with limited cases have been reported. A summary of the reported cases (including our series) has demonstrated that the DAVF located within the foramen magnum region are fed by dural branches of external carotid arteries and vertebral arteries, and involve the perimedullary veins. The typical patient is described as a middle-aged man, presenting with a slowly

Conclusion

Onyx embolisation is a feasible and safe alternative to open surgery in the treatment of selective DAVF at the foramen magnum. The balloon-augmented technique becomes a valuable complement, widens indications for transarterial Onyx packing of these lesions, and improved safety of the procedure. Nevertheless, additional, large series with long-term follow-up are necessary to determine the efficacy and safety of this relatively new method.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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    Guobiao Liang and Xu Gao contributed equally to this work.

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