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

Abstract

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. 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. 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. 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.