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Pre-operative embolization followed by clipping of Cognard type V dural arteriovenous fistula
  1. Krishna C Joshi,
  2. André Beer-Furlan,
  3. R Webster Crowley,
  4. Stephan A Munich
  1. Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
  1. Correspondence to Dr Krishna C Joshi, Department Neurological Surgery, Rush University Medical Center, Chicago, IL 60612, USA; Krishna_C_Joshi{at}rush.edu

Abstract

Cognard type V dural arteriovenous fistulas (DAVFs) are a rare type of cerebrovascular malformation characterized by congestion of the perimedullary venous system and often lead to devastating spinal cord pathology if left untreated. We present a unique case in which a middle-aged patient presented with history of gradually progressive weakness in both lower limbs for 6 months and sudden onset of weakness in both upper limbs and face over 3 days. Magnetic resonance imaging (MRI) showed edema in the cervicomedullary junction. Further investigation with conventional angiogram revealed a Cognard type V fistula in the right cerebellopontine angle with multiple feeders from both right external and internal carotid arteries, with drainage into the cerebellar cortical veins and spinal perimedullary veins. We first attempted embolization of the fistula with PHIL liquid embolic system (MicroVention, Tustin, CA, USA) followed by surgical ligation of the fistula. The patient made a remarkable recovery and was symptom-free at his 3-month follow-up. His follow-up MRI showed complete resolution of the edema in his cervicomedullary junction. This case highlights the fact that a combined approach may be often needed to treat these complex fistulas (video 1).

Video 1

  • fistula
  • liquid embolic material
  • spinal cord

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Footnotes

  • Contributors KCJ, ABF, and SAM conceived the presented idea. KCJ, ABF, RWC, and SAM were involved in performing the procedure. KCJ, ABF, and SAM were involved in editing the video. All authors reviewed, discussed the results, and contributed to the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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