gms | German Medical Science

63rd Annual Meeting of the German Society of Neurosurgery (DGNC)
Joint Meeting with the Japanese Neurosurgical Society (JNS)

German Society of Neurosurgery (DGNC)

13 - 16 June 2012, Leipzig

Progressive cervical myelopathy caused by tentorial dural arteriovenous fistula: case report

Meeting Abstract

  • U. Barcik - Neurochirurgische Klinik, Klinikum St Marien, Amberg
  • N. Thon - Klinik und Poliklinik für Neurochirurgie, Klinikum der Universität München, Campus Großhadern, München
  • T. Finkenzeller - Radiologische Klinik, Klinikum Weiden, Weiden
  • C. Schichor - Klinik und Poliklinik für Neurochirurgie, Klinikum der Universität München, Campus Großhadern, München
  • R. Megele - Neurochirurgische Klinik, Klinikum St Marien, Amberg

Deutsche Gesellschaft für Neurochirurgie. Japanische Gesellschaft für Neurochirurgie. 63. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Japanischen Gesellschaft für Neurochirurgie (JNS). Leipzig, 13.-16.06.2012. Düsseldorf: German Medical Science GMS Publishing House; 2012. DocP 051

DOI: 10.3205/12dgnc438, URN: urn:nbn:de:0183-12dgnc4381

Published: June 4, 2012

© 2012 Barcik et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Outline

Text

Background and importance: Tentorial dural arteriovenous fistula (TDAVF) can cause progressive myelopathy. The clinical course can be aggressive and treatment is mandatory. Although a rare disease we highlight the importance of considering TDAVF in the differential diagnosis of cervical myelopathy.

Clinical presentation: A 58-year-old man presented with a 5-months history of gait instability and urinary incontinence. He was found to suffer from dysphagia and dysarthria. In addition, he showed dysautonomic disorders consistent with bulbar involvement. Magnetic resonance imaging revealed a lesion extending from the inferior pons to the upper cervical spine. The differential diagnostic considerations included brainstem glioma, demyelinating conditions, brainstem encephalitis, anterior spinal artery syndrome and vasculitis, to name a few. An open biopsy was performed but the pathologic workup showed neither tumor nor inflammation. Intraoperative prominent blood vessels around the medulla oblongata and cervical spinal cord were observed. The patient’s clinical status deteriorated despite a course of steroids. Additional review of the MR-images together with the surgical finding of prominent perimedullar vessels revealed flow void signal in T2-weighted images in the caudal pons and ventral medulla oblongata as well as peripontine, highly suspicious of an underlying vascular cause of the myelopathy. Angiographic evaluation was performed which showed a left-sided TDAVF supplied by tortuous vessels arising from the meningohypophyseal trunk at the cavernous segment of the internal carotid artery (basal tentorial artery of Bernasconi and Cassinari) and draining into lateral pontomesencephalic veins. The venous drainage was clipped via a left suboccipital microsurgical approach using indocyanine green (ICG). A control carotid angiogram was done 2 days after operation, confirming occlusion of the TDAVF. At the last follow up the patient was discharged from the rehabilitation unit. He made some good recovery. He was able to ambulate, communicate and swallow.

Conclusion: TDAVF is a rare but curable cause of progressive cervical myelopathy. Correct diagnosis may be delayed by unspecific clinical symptoms and subtle signs on imaging evaluation. Surgical treatment is well established.

Abbreviations: TDAVF,Tentorial dural arteriovenous fistula; ICG, indocyanine green; CTA, CT angiography.