title: Concurrent dural and perimedullary arteriovenous fistulas at the craniocervical junction: case series with special reference to angioarchitecture.
abstract: OBJECTIVE
  Dural arteriovenous fistulas (DAVFs) and perimedullary arteriovenous fistulas (PAVFs) are uncommonly associated in the craniocervical junction. The purpose of this study was to describe the clinical and angiographic characteristics of such concurrent lesions.
  
  
  METHODS
  Authors reviewed 9 cases with a coexistent DAVF and PAVF at the craniocervical junction. Clinical presentation, angiographic characteristics, intraoperative findings, and treatment outcomes were assessed.
  
  
  RESULTS
  All patients (male/female ratio 5:4; mean age 66.3 years) presented with subarachnoid hemorrhage. Angiography revealed that 8 patients had both a DAVF and PAVF on the same side, whereas 1 patient had 3 arteriovenous fistulas, 1 DAVF, and 1 PAVF on the right side and 1 DAVF on the left side. All of the fistulas shared dilated perimedullary veins (anterior spinal vein, 7 cases; anterolateral spinal vein, 2 cases) as a main drainage route. The shared drainage route was rostrally directed in 8 of 9 cases. Eight patients exhibited an arterial aneurysm on the distal side of the feeding arteries to the PAVF, and the aneurysm in each case was intraoperatively confirmed as a bleeding point. One patient had ruptured venous ectasia at the perimedullary fistulous point. All patients underwent direct surgery via a posterolateral approach. No recurrence was observed in the 4 patients who underwent postoperative angiography, and no rebleeding event was recorded among any of the 9 patients during the follow-up period (mean 38.4 months).
  
  
  CONCLUSIONS
  The similarity of the angioarchitecture and the close anatomical relationship between DAVF and PAVF at the craniocervical junction suggested that these lesions are pathogenetically linked. The pathophysiological mechanism and anatomical features of these lesions represent a unique vascular anomaly that should be recognized angiographically to plan a therapeutic strategy.
authors.affiliation: Department of Neuroendovascular Therapy, Tohoku University Graduate School ofMedicine, Sendai, Japan. kenmina@nsg.med.tohoku.ac.jp
authors.forename: Kenichi
authors.initials: K
authors.lastname: Sato
authors.forename: Toshiki
authors.initials: T
authors.lastname: Endo
authors.forename: Kuniyasu
authors.initials: K
authors.lastname: Niizuma
authors.forename: Miki
authors.initials: M
authors.lastname: Fujimura
authors.forename: Takashi
authors.initials: T
authors.lastname: Inoue
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Shimizu
authors.forename: Teiji
authors.initials: T
authors.lastname: Tominaga
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging* / Q000601:surgery; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging* / Q000601:surgery; D002533:Cerebral Angiography; D002550:Cerebral Veins / Q000000981:diagnostic imaging* / Q000601:surgery; D002574:Cervical Vertebrae / Q000098:blood supply / Q000601:surgery; D003399:Craniotomy; D005260:Female; D005539:Foramen Magnum / Q000098:blood supply / Q000601:surgery; D006801:Humans; D007796:Laminectomy; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging / Q000601:surgery; D014711:Vertebral Artery / Q000000981:diagnostic imaging* / Q000601:surgery