Microsurgical Treatment of Foramen Magnum Cognard Type V Dural Arteriovenous Fistula: 2-Dimensional Operative Video

Mithun G. Sattur, Karl R. Abi-Aad, Alexandra E. Richards, Brian W. Chong, Matthew E. Welz, Fucheng Tian, Bernard R. Bendok

Research output: Contribution to journalArticle

Abstract

Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.

Original languageEnglish (US)
Pages (from-to)E203
JournalOperative neurosurgery (Hagerstown, Md.)
Volume17
Issue number5
DOIs
StatePublished - Nov 1 2019

Fingerprint

Foramen Magnum
Central Nervous System Vascular Malformations
Veins
Fistula
Angiography
Thorax
Spinal Cord Diseases
Spinal Cord
Magnetic Resonance Imaging
Arachnoid
Therapeutics
External Carotid Artery
Prone Position
Spinal Canal
Indocyanine Green
Vertebral Artery
Craniotomy
Informed Consent
Dissection
Lower Extremity

Keywords

  • Cognard classification
  • Dural arteriovenous fistula
  • Foramen magnum fistula
  • ICG
  • Microsurgery
  • Spinal angiography
  • Venous hypertension

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Microsurgical Treatment of Foramen Magnum Cognard Type V Dural Arteriovenous Fistula : 2-Dimensional Operative Video. / Sattur, Mithun G.; Abi-Aad, Karl R.; Richards, Alexandra E.; Chong, Brian W.; Welz, Matthew E.; Tian, Fucheng; Bendok, Bernard R.

In: Operative neurosurgery (Hagerstown, Md.), Vol. 17, No. 5, 01.11.2019, p. E203.

Research output: Contribution to journalArticle

Sattur, Mithun G. ; Abi-Aad, Karl R. ; Richards, Alexandra E. ; Chong, Brian W. ; Welz, Matthew E. ; Tian, Fucheng ; Bendok, Bernard R. / Microsurgical Treatment of Foramen Magnum Cognard Type V Dural Arteriovenous Fistula : 2-Dimensional Operative Video. In: Operative neurosurgery (Hagerstown, Md.). 2019 ; Vol. 17, No. 5. pp. E203.
@article{b64df140ebe94d518c85d2c049c4ca57,
title = "Microsurgical Treatment of Foramen Magnum Cognard Type V Dural Arteriovenous Fistula: 2-Dimensional Operative Video",
abstract = "Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.",
keywords = "Cognard classification, Dural arteriovenous fistula, Foramen magnum fistula, ICG, Microsurgery, Spinal angiography, Venous hypertension",
author = "Sattur, {Mithun G.} and Abi-Aad, {Karl R.} and Richards, {Alexandra E.} and Chong, {Brian W.} and Welz, {Matthew E.} and Fucheng Tian and Bendok, {Bernard R.}",
year = "2019",
month = "11",
day = "1",
doi = "10.1093/ons/opz030",
language = "English (US)",
volume = "17",
pages = "E203",
journal = "Operative Neurosurgery",
issn = "2332-4252",
publisher = "Lippincott Williams and Wilkins",
number = "5",

}

TY - JOUR

T1 - Microsurgical Treatment of Foramen Magnum Cognard Type V Dural Arteriovenous Fistula

T2 - 2-Dimensional Operative Video

AU - Sattur, Mithun G.

AU - Abi-Aad, Karl R.

AU - Richards, Alexandra E.

AU - Chong, Brian W.

AU - Welz, Matthew E.

AU - Tian, Fucheng

AU - Bendok, Bernard R.

PY - 2019/11/1

Y1 - 2019/11/1

N2 - Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.

AB - Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.

KW - Cognard classification

KW - Dural arteriovenous fistula

KW - Foramen magnum fistula

KW - ICG

KW - Microsurgery

KW - Spinal angiography

KW - Venous hypertension

UR - http://www.scopus.com/inward/record.url?scp=85073183599&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85073183599&partnerID=8YFLogxK

U2 - 10.1093/ons/opz030

DO - 10.1093/ons/opz030

M3 - Article

C2 - 30919907

AN - SCOPUS:85073183599

VL - 17

SP - E203

JO - Operative Neurosurgery

JF - Operative Neurosurgery

SN - 2332-4252

IS - 5

ER -