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Table of Contents    
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 661-663

A dural arterioveous fistula at the foramen magnum treated with transarterial Onyx embolization

Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Date of Submission05-Jul-2012
Date of Decision26-Sep-2012
Date of Acceptance16-Nov-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Liemei Guo
Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.105215

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How to cite this article:
Guo L, Qiu Y. A dural arterioveous fistula at the foramen magnum treated with transarterial Onyx embolization . Neurol India 2012;60:661-3

How to cite this URL:
Guo L, Qiu Y. A dural arterioveous fistula at the foramen magnum treated with transarterial Onyx embolization . Neurol India [serial online] 2012 [cited 2021 Jan 18];60:661-3. Available from:


A 45-year-old male was admitted with headache and vomiting of one-day duration. Physical examination revealed neck stiffness. Cranial computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) [Figure 1]a, and angiography revealed a dural arteriovenous fistula (DAVF) with a varix located at the foramen magnum [Figure 1]b-d. The DAVF was fed only by a branch of the left vertebral artery (VA) with drainage cephaladly to the confluence of sinuses, and caudally to the internal jugular vein and medullary vein [Figure 1]b. Transarterial Onyx embolization was considered because the DAVF was supplied only by a branch of the left VA, which made the transarterial embolization feasible and simple. Under general anesthesia, catheterization was performed via the transfemoral approach and systemic hepharinization was achieved during the procedures. The Marathon microcatheter (MTI-EV3, Irvine, CA, USA) used for the embolization procedure was dimethylsulfoxide dimethylsulfoxide (DMSO)-compatible. The microcatheter tip was placed as close as possible to the DAVF nidus to ensure that the liquid embolic agent could penetrate and occlude the lesion. Once the microcatheter tip was advanced to reach the optimal position, the injection of Onyx-18 (MTI-EV3) was carried out. Whenever any venous migration was found the injection was stopped to allow for solidification and subsequently the injection was continued until the DAVF was completely obliterated [Figure 1]e. The post-procedure course was uneventful without any complications and follow-up angiography at 6 months did not reveal any recurrent lesions [Figure 1]f.
Figure 1: Preoperative and postoperative images of a patient with DAVF located at the foramen magnum, who presented with SAH. Cranial CT scans showed SAH, with hemorrhage mostly located at the occipital
ventricle and bilateral tentoriums (a, arrows). Cerebral angiography revealed a DAVF located at the foramen magnum. The DAVF was fed only by a branch of the left vertebral artery, and it drained cephaladly to
the confluence of the sinuses, and caudally to internal jugular vein and medullary vein (b, arrows show the draining directions). Right vertebral artery angiography showed that the DAVF was not fed by the branches
of the right vertebral artery (c) The DAVF with a varix (arrow), which indicated the origin of hemorrhage, was evident from the reconstruction picture of the angiography (d) Post-embolization angiography revealed the complete disappearance of the DAVF and draining veins (e) Follow-up angiographic assessments at 6 months did not reveal any recurrent lesions (f)

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DAVFs at the foramen magnum are rare, especially in patients presenting with SAH. [1] Anatomically, DAVFs at the foramen magnum are supplied by the branches of the vertebral artery, or the occipital artery or ascending pharyngeal artery. Importantly, these arteries may have a complicated anastomosis with each other, [1],[2] which sometimes poses great difficulties for both surgical disconnection and transarterial embolization. In addition to the feeders, venous drainage also should be considered carefully, as it is not only the principal factor related to hemorrhage, but also the issue that guides the treatment strategy. It has been reported that DAVFs with retrograde venous outflow into leptomeningeal and/or cortical veins are at high risk for hemorrhage, and require aggressive management aimed at cure. [3] In addition, the presence of varices of the draining vein and cephalad-directed drainage pathways, which suggested venous hypertension, also could result in high risk of hemorrhage. [1],[4]

Generally, DAVFs can be treated by surgical resection, transarterial or transvenous embolization, or stereotactic radiosurgery, sometimes a combination of procedures may be needed. [1],[5],[6],[7] Regarding DAVFs at the foramen magnum, microsurgical disconnection of the shunt is the option, because with multiple and small feeders, endovascular treatment may not be possible. [1] However, surgical treatment may be associated with significant morbidity and even mortality. Thus, there is a need for considering alternative treatment approaches. In the past one decade, there have been remarkable advances in endovascular techniques providing highly flexible, hydrophilic-coated catheters that allow more distal navigation. Marathon and Echelon-10 microcatheters enable complete obliteration of DAVFs via the transarterial route. [7],[8] Onyx is a new non-adhesive liquid embolic agent that tends to layer concentrically within the vessel, whereas acrylic glue tends to form discrete plugs that may fragment and propagate with flow. This characteristic of Onyx makes possible the progression of the microcatheter along the feeders and the progressive closure of the artery and arterialized draining vein using a transarterial method. [7],[8] Although Onyx is more expensive, we still regard Onyx as the "gold standard", because its non-adhesive property and a long solidification time allows the surgeon far greater latitude in varying the rate of injection and the amount of the agent delivered during a single injection. Owing to its capacity for penetrating the shunt, we think Onyx is en effective embolic agent and holds significant promise for future endovascular therapy for curing DAVFs. Moreover, transarterial Onyx embolization could be an alternative for treating DAVFs at the foramen magnum.

  References Top

1.Guo LM, Zhou HY, Xu JW, Wang GS, Tian X, Wang Y, et al. Dural arteriovenous fistula at the foramen magnum presenting with subarachnoid hemorrhage: Case reports and literature review. Eur J Neurol 2010;17:684-91.  Back to cited text no. 1
2.Rhoton AL Jr. The foramen magnum. Neurosurgery 2000;47:S155-93.  Back to cited text no. 2
3.Borden JA, Wu JK, Shucart WA. A proposed classification for spinal and cranial duralarteriovenousfis-tulous malformations and implications for treatment. J Neurosurg 1995;82:166-79.  Back to cited text no. 3
4.Aviv RI, Shad A, Tomlinson G, Niemann D, Teddy PJ, Molyneux AJ, et al. Cervical duralarteriovenous fistulae manifesting as subarachnoid hemorrhage: Report of two cases and literature review. AJNR Am J Neuroradiol 2004;25:854-8.  Back to cited text no. 4
5.Tomasello F, Conti A. Dural arteriovenous fistulae: Surgery in the golden age of onyx. World Neurosurg 2012;77:477-8.  Back to cited text no. 5
6.Ghobrial GM, Marchan E, Nair AK, Dumont AS, Tjoumakaris SI, Gonzalez LF, et al. Dural Arteriovenous Fistulas: A review of the literature and a presentation of a single institution's experience. World Neurosurg 2012 [Epub ahead of print].  Back to cited text no. 6
7.Macdonald JH, Millar JS, Barker CS. Endovascular treatment of cranial duralarteriovenous fistulae: A single-centre, 14-year experience and the impact of Onyx on local practise. Neuroradiology 2010;52:387-95.  Back to cited text no. 7
8.Stiefel MF, Albuquerque FC, Park MS, Dashti SR, McDougall CG. Endovascular treatment of intracranial duralarteriovenous fistulae using Onyx: A case series. Neurosurgery 2009;65:132-40.  Back to cited text no. 8


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