Ischemic complications in the neurosurgical and endovascular treatments of craniocervical junction arteriovenous fistulas: a multicenter study

Keisuke TakaiDepartment of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo;

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Toshiki EndoDepartment of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Miyagi;
Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi;

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Toshitaka SekiDepartment of Neurosurgery, Hokkaido University, Graduate School of Medicine, Sapporo;

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Tomoo InoueDepartment of Neurosurgery, Tohoku University, Graduate School of Medicine, Sendai, Miyagi;
Department of Neurosurgery, Kohnan Hospital, Sendai, Miyagi;

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Izumi KoyanagiDepartment of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo; and

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Takafumi MitsuharaDepartment of Neurosurgery, Hiroshima University Hospital, Hiroshima, Japan

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and the Neurospinal Society of Japan CCJ AVF Study Investigators
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OBJECTIVE

A recent comparative analysis between neurosurgical and endovascular treatments for craniocervical junction (CCJ) arteriovenous fistulas (AVFs) revealed better treatment outcomes in the neurosurgery group than in the endovascular group. This finding was attributed to the higher than expected rate of ischemic complications in the endovascular group than in the neurosurgery group (26% vs 7.7%, p = 0.037). The aim of the present study was to describe ischemic complications associated with treatments for CCJ AVFs.

METHODS

This descriptive study was authorized by the Neurospinal Society of Japan. Data from 97 consecutive patients with CCJ AVFs who underwent neurosurgical (n = 78) or endovascular (n = 19) treatment between 2009 and 2019 were collected from 29 centers. The primary endpoints were details on ischemic complications and their risk factors. Secondary endpoints were details on other complications.

RESULTS

Among all major complications, ischemic complications were the most common (11% of 97 patients), followed by hemorrhagic complications (7.2%), hydrocephalus (2.1%), and CSF leakage (2.1%). Ischemic complications included 8 spinal, 2 brainstem, and 1 cerebellar infarctions. Iatrogenic occlusion of the anterior or posterior spinal artery from the radiculomedullary or radiculopial arteries caused these complications. Ischemic complications resulted in neurological deficits, including motor paresis, sensory disturbances, and brainstem dysfunction. The modified Rankin Scale score was 3 or higher in 36% of patients with ischemic complications at the final follow-up of 23 months. Risk factors associated with ischemic complications were endovascular treatment (OR 4.3, 95% CI 1.1–16) and spinal feeding arteries (OR 3.8, 95% CI 1.03–14). Most of the other complications were addressed by additional treatment without permanent neurological deficits.

CONCLUSIONS

Among ischemic complications associated with treatments for CCJ AVFs, spinal infarctions were the most common and were mostly attributed to endovascular procedures for CCJ AVFs fed by spinal arteries. These results support the use of neurosurgery as the first-line treatment for CCJ AVFs.

ABBREVIATIONS

ASA = anterior spinal artery; AVF = arteriovenous fistula; CCJ = craniocervical junction; mRS = modified Rankin Scale; NBCA = N-butyl cyanoacrylate; PSA = posterior spinal artery.
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Figure from Kim et al. (pp 1601–1609).

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