Artikel
Management of craniocervical dural arteriovenous malformations
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Veröffentlicht: | 20. Mai 2009 |
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Gliederung
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Objective: To describe the specifics of the subgroup of cranial dural arteriovenous malformations which are located at the craniocervical junction and present with characteristic features due to venous congestion in the upper, pontine or pontomedullary brainstem compartment.
Methods: 11 patients with craniocervical dural arteriovenous malformations were identified. All patients underwent superselective angiography. Feeding vessels were typically the ascendant pharyngeal and the external occipital arteries. Collateral feeders may originate from tentorial branches or the middle menigeal artery.
Results: The symptoms are those of insidious onset of brainstem dysfunction but never acute. None of the lesions in our series of 11 cases had bled. The arteriovenous fistulous point, which is usually within a small nidus, is typically around the jugular foramen.
Therapy consisted in an attempt at embolization with diluted, very liquid acrylic material because the feeding vessels are thin and the distance to the nidus is long. Occlusion was achieved in more than 50% of the cases. If the embolization was incomplete or appeared to dangerous because of appearing collaterals to the spinal artery, surgical exposure was performed to obliterate the fistulous point either by coagulation, clipping or transection after coagulation. In one patient the symptoms resolved, in 8 patients the symptoms improved, one patient deteriorated and one patient died.
Conclusions: The prognosis of neurological deficits after obliteration of a csDAVF is unpredictable. Surgical therapy as well as complete embolization result in an immediate change of haemodynamics which angiographically then appear ”normal” but may be inappropriate in the sense of hyperperfusion or reperfusion injury. It is hypothesized that preembolization with timely surgical intervention thereafter allows for more gradual adaptation.