Cervical Dural Arteriovenous Fistula Presenting With Brainstem Dysfunction

Abstract

We present a rare case of cervical dural arteriovenous fistula (C-DAVF) presenting with brainstem dysfunction. We discuss the details of the case and review previous articles on C-DAVF. Our case study illustrates the relation between uncommon neurologic findings and altered hemodynamics resulting from the anatomic features of the neural pathway. Based on a review of 31 cases of C-DAVFs published since 1990 (30 patients, including our own), we sought to determine which surgical treatment for C-DAVF, endovascular surgery, or direct interruption of the draining vein, is more effective. A combination of endovascular techniques and direct interruption procedures was successful in curing the C-DAVF in our patient. The selection between endovascular surgery and surgical interruption in the treatment of C-DAVF is controversial. We sought to identify the characteristics and surgical methods most closely associated with complete cure for C-DAVF. RESULTS.: According to the reports on 31 cases of C-DAVF treated surgically (including our own), 20 DAVFs were managed by open surgery with interruption, 8 were treated by endovascular surgery, and 3 underwent a combined open and endovascular approach. Twenty-one patients showed symptomatic improvement or stabilization without additional treatment during the postsurgical course. Surgical revisions were performed in 3 patients (10.0%) (including the present case), all of whom initially underwent endovascular surgery. None of the cases treated by surgical interruption of the draining vein showed signs of recurrence. Surgical interruption of the draining vein is more effective than endovascular surgery in bringing about an absolute cure for C-DAVF. In exceptional cases, however, endovascular surgery is the preferred treatment. This is particularly so for elderly or medically compromised cases with contraindications against general anesthesia, as well as for moribund cases which, like our own case, present with rapidly deteriorating neurologic status on admission.