Traumatic arteriovenous fistula of the posterior inferior cerebellar artery treated with endovascular coil embolization: case report.
BACKGROUND
High-flow intracranial arteriovenous (AV) fistulas associated with giant varices are rare lesions. These varices can present with symptoms from mass effect, spontaneous hemorrhage, and seizures to cardiac failure. Direct AV fistulas of the posterior inferior cerebellar artery (PICA) are extremely rare lesions, with only two cases reported in the literature.


METHODS
The authors present an unusual case of a 25-year-old male with a direct AV fistula of the PICA that resulted from a fracture of the occipital condyle. This high-flow AV fistula drained into a giant varix of the vein of the lateral recess that compressed the brainstem, resulting in a Wallenberg syndrome. The patient underwent embolization of the proximal PICA feeding the fistula with a Guglielmi detachable coil (GDC), which resulted in thrombosis of the varix. A postembolization angiogram showed occlusion of the PICA AV fistula and draining varix. A computed tomography (CT) scan performed at a 10-month follow-up visit showed dramatic decompression of the brainstem. Although the patient continued to have some sensory changes secondary to Wallenberg syndrome, he was otherwise doing well neurologically.


CONCLUSIONS
The treatment of this lesion is difficult because of its location near the brainstem. Postocclusion edema or hemorrhage can result in mass effect and life-threatening brainstem compression. Our patient, whose AV fistula was caused by trauma, was treated effectively with GDC embolization.
Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA.
James K
JK
Liu
David
D
Decker
Michael S
MS
Tenner
William T
WT
Couldwell
Bennie W
BW
Chiles
D000328:Adult; D001158:Arteries / Q000293:injuries; D001164:Arteriovenous Fistula / Q000175:diagnosis / Q000628:therapy*; D001933:Brain Stem / Q000473:pathology; D002531:Cerebellum / Q000098:blood supply*; D002533:Cerebral Angiography; D020214:Cerebrovascular Trauma / Q000175:diagnosis / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted; D021621:Imaging, Three-Dimensional; D014854:Lateral Medullary Syndrome / Q000175:diagnosis / Q000628:therapy; D008279:Magnetic Resonance Imaging; D008297:Male; D009460:Neurologic Examination; D009777:Occipital Bone / Q000293:injuries; D012887:Skull Fractures / Q000150:complications / Q000175:diagnosis; D014057:Tomography, X-Ray Computed; D014648:Varicose Veins / Q000175:diagnosis / Q000628:therapy