Late-developing posttraumatic dural arteriovenous fistula of the vertebral artery: illustrative case

Hanna E Schenck Departments of Neurosurgery and
School of Mental Health and Neuroscience, Faculty of Health, Medicine and Lifesciences, Maastricht University, Maastricht, The Netherlands; and

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Thomas B Fodor Faculty of Health, Medicine and Lifesciences, Maastricht University, Maastricht, The Netherlands

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Bart A. J. M Wagemans Interventional Radiology, Maastricht University Medical Center, Maastricht, The Netherlands

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Roel H. L Haeren Departments of Neurosurgery and
School of Mental Health and Neuroscience, Faculty of Health, Medicine and Lifesciences, Maastricht University, Maastricht, The Netherlands; and

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BACKGROUND

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from damage to the VA, most frequently following cervical spine trauma. In most traumatic cases, the dAVF develops and manifests shortly after trauma.

OBSERVATIONS

A patient was admitted after a fall from the stairs causing neck pain. Computed tomography of the cervical spine revealed a Hangman’s fracture, and angiography showed a left VA dissection. The patient was treated with a cervical brace and clopidogrel. Three weeks after trauma, the patient was admitted because of bilateral leg ataxia, dizziness, and neck pain. Repeat imaging revealed increased displacement of the cervical fracture and a dAVF from the left VA with retrograde filling of the dAVF from the right VA. Embolization of the dAVF using coils proximally and distally to the dAVF was performed prior to placing a halo brace. At 6 months, all symptoms had disappeared and union of the cervical spine fracture had occurred.

LESSONS

This case report emphasizes the need for follow-up angiography after traumatic VA injury resulting from cervical spine fracture and underlines important treatment considerations for successful obliteration of a dAVF of the VA.

ABBREVIATIONS

AVF = arteriovenous fistula; CT = computed tomography; CTA = computed tomography angiography; dAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; ICA = internal carotid artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery

BACKGROUND

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from damage to the VA, most frequently following cervical spine trauma. In most traumatic cases, the dAVF develops and manifests shortly after trauma.

OBSERVATIONS

A patient was admitted after a fall from the stairs causing neck pain. Computed tomography of the cervical spine revealed a Hangman’s fracture, and angiography showed a left VA dissection. The patient was treated with a cervical brace and clopidogrel. Three weeks after trauma, the patient was admitted because of bilateral leg ataxia, dizziness, and neck pain. Repeat imaging revealed increased displacement of the cervical fracture and a dAVF from the left VA with retrograde filling of the dAVF from the right VA. Embolization of the dAVF using coils proximally and distally to the dAVF was performed prior to placing a halo brace. At 6 months, all symptoms had disappeared and union of the cervical spine fracture had occurred.

LESSONS

This case report emphasizes the need for follow-up angiography after traumatic VA injury resulting from cervical spine fracture and underlines important treatment considerations for successful obliteration of a dAVF of the VA.

ABBREVIATIONS

AVF = arteriovenous fistula; CT = computed tomography; CTA = computed tomography angiography; dAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; ICA = internal carotid artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from injury to the VA, most frequently following cervical spine trauma.1 Recent reviews have estimated that injury to the VA is present in 0.77% of hospitalized patients with blunt head trauma.2,3 Management of injury to the VA is controversial given the lack of high-level evidence to guide decision making. Here, we present the rare case of a patient admitted with a Hangman’s fracture and unilateral VA dissection who experienced late symptoms of vertebrobasilar ischemia as a result of a dAVF of the VA, which probably developed as an evolution of the VA dissection.

Illustrative Case

A 69-year-old male patient with an extensive cardiovascular history presented to the emergency department after a fall from the stairs. On admission, the patient reported neck pain without neurological symptoms.

Investigation

Computed tomography (CT) of the cervical spine showed a Hangman’s fracture type 2 extending into the left vertebral foramen and a fracture through the spinous process of C3 (Fig. 1). A CT angiography (CTA) revealed a contrast-filling defect of the left VA at the level of C2–C3, suggesting a dissection of the VA, and occlusion of the right internal carotid artery (ICA) (Fig. 2). Pharmacological therapy with clopidogrel was advised (75 mg, 1×/day). In the absence of neurological symptoms and signs of ligament injury, a cervical brace was recommended with follow-up imaging 2 weeks later. The patient remained stationary for continuous heart monitoring of the suspected heart arrhythmias.

FIG. 1
FIG. 1

Computed tomography (CT) scans of the cervical spine at admission. A: Axial CT scan of the cervical spine showing a Hangman’s fracture: a bilateral fracture through the pars interarticularis of C2 (red arrows). B: Axial CT scan of the cervical spine showing a fracture on the left side of the C2 body (red arrow). C: Axial CT scan of the cervical spine showing a fracture through the spinous process of C3 with a 7-mm diastasis (red arrow), classified as a type A0 according to the AO classification. D: Axial CT scan of the cervical spine showing the C2 fracture close to the left transverse foramen (red arrow). E: Sagittal CT scan of the cervical spine showing a 4-mm horizontal posterior displacement of the lamina of C2 (Hangman’s fracture type II based on the Levine and Edwards classification). F: Sagittal CT scan of the cervical spine showing a fracture involving the left C2–C3 facet (red arrow). AO = “Arbeitsgmeinschaft für Osteosynthesefragen” (AO Foundation).

FIG. 2
FIG. 2

CT angiography (CTA) of the cervical spine at admission (A) and 3 weeks after trauma (B–D). Axial CTA of the spine at admission (A), revealing a subtle contrast-filling defect of the left vertebral artery (VA) at the level of C2–C3 suggestive of a dissection of the VA (red arrow). Axial (B), sagittal (C), and coronal (D) CTA of the cervical spine 3 weeks after trauma, revealing a 9-mm aneurysmal dilation (red arrow) of the left VA at the level of C2–C3, and (dural) varicose veins (blue arrows).

Three days later, the patient developed binocular diplopia, which was related to a vertebrobasilar insufficiency, most likely as a result of the dissection of the VA. Treatment with clopidogrel was continued. Symptoms spontaneously resolved a few days later. After 7 days, the patient was discharged from the hospital.

At the outpatient follow-up visit 2 weeks after trauma, follow-up radiographs of the cervical spine showed increased anterior displacement of the C1–C2 complex in relation to C3 and reduced lordosis (Fig. 3). The absence of neck pain and neurological symptoms warranted observation. Six days later, readmission occurred due to neck pain, bilateral leg ataxia, and dizziness. Repeated radiography and CT of the cervical spine showed further progression of the anterior displacement of C2 in relation to C3 (Fig. 3), and CTA revealed venous dilation, large varices, and possible aneurysmal dilation of the left VA at the level of C2–C3 (Fig. 2).

FIG. 3
FIG. 3

Radiographs of the cervical spine at admission (A) and at follow-up (B–D). Lateral radiograph (A) of the cervical spine 1 day after trauma, showing the fracture through the pars interarticularis of C2 (red arrow) with dorsal displacement of the posterior complex of C2. Lateral radiograph (B) of the cervical spine 2 weeks after trauma, revealing a subtle angulation and increased distance of the lamina of C2 from the anterior complex of C2 (red arrow). Lateral radiograph (C) of the cervical spine 3 weeks after trauma, showing a further increased antero-position of C2 in relation to C3 (red arrow). Lateral radiograph (D) of the cervical spine 4 months after trauma and after embolization of the dural arteriovenous fistula (dAVF) at the level of C2–C3, revealing a correction of the antero-position of C2 relative to C3 (red arrow). The coils proximal and distal to the dAVF can also be noted (stars).

Treatment

Subsequent digital subtraction angiography (DSA) demonstrated abnormal early venous filling and dilated congestive veins in combination with a venous aneurysm at the level of the dissection associated with a dAVF and an absent antegrade filling of the basilar artery from the left VA (Fig. 4). The dAVF was occluded by coil embolization with the use of multiple detachable neuro coils (Stryker Target XL, standard and soft) ranging from 3 to 6 mm and placed proximal and distal to the dAVF.

FIG. 4
FIG. 4

Digital subtraction angiography (DSA) of the left VA illustrating the dAVF. Lateral DSA (A) showing an aneurysmal dilation (red arrow) at the level of the left VA with early filling of ectatic veins (blue arrows). Coronal DSA (B) after contrast injection to the right VA showing filling of the left VA and the left posterior inferior cerebellar artery (PICA; yellow arrow), thereby confirming adequate collateral perfusion via the right VA. Coronal DSA (C) after contrast injection to the right VA showing flow from the right VA to the left VA with retrograde flow towards the dAVF (red arrow). Coronal view (D) after contrast injection to the right VA and following distal embolization of the dAVF, showing an absence of filling of the left VA, while flow to the left PICA (yellow arrow), is preserved.

Outcomes

Follow-up DSA demonstrated absent early venous filling and no residual flow in the coil-embolized part of the left VA, suggesting complete obliteration of the fistula. Collateral flow to the posterior circulation via the right VA was sufficient, and retrograde filling of the posterior inferior cerebellar artery (PICA) on the left side was observed (Fig. 4). Thereafter, the unstable cervical C2 fracture was stabilized externally with a halo brace for 3 months. At 6 months, all symptoms had resolved and radiography demonstrated improved cervical lordosis (Fig. 3).

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

We described the case of a patient developing a dAVF of the VA following cervical spine trauma. Here, it is likely that the patient’s cardiovascular comorbidities, instability of the cervical fracture with increasing displacement, and proximity of the fracture to the transverse foramen preceded development of the fistula. More specifically, the initial trauma was likely to have caused the dissection, which, in turn, may have led to thrombus formation (as suggested by the short episode of symptoms denoting infarction in the posterior circulation). This may have resulted in altered venous hemodynamics, promoting pathological recanalization in the form of a fistula.4 To improve our understanding of this rare entity, we reviewed and summarized the literature on traumatic dAVFs of the VA (Table 1).5–16

TABLE 1

Case reports on traumatic vertebral artery arteriovenous fistulas

Authors & YearAge (yrs)SexFracture TypeAVF Location, SideTiming of Diagnosis of AVFPresenting SymptomsAVF TreatmentCervical Fracture TreatmentTreatment OrderOutcome
Avellanosa et al., 1977554FHangman’s fracture, C1 arch fractureC1, rt VA1 day laterIncreased muscle tone upper extremitiesOpen vertebral & intracranial clipping after 4 wksCervical collar1st fracture healing, then AVFPartial neurological symptom remission: remaining ataxia
Hayes et al., 1980676MC2 anterolisthesis w/ regard to C3, spinous process fracture C4-C5C2-C3, lt VA3 days after injuryNeck swelling, cervical bruit, lt-sided paresisSurgical ligation of VA at subclavian levelC2-C3 wiring1st fracture, then AVFRespiratory decompensation & death due to pneumonia
Okuchi et al., 1994745MC1-C2 fracture w/ C2 subluxationC1-C2, rt VAShortly after admissionUncontrollable nasal bleeding, ataxic respiration, low blood pressureFailed direct balloon occlusion of fistula; trapping of both proximal & distal ends of involved VA from C5 to C1Halo1st AVF, then fractureUnknown
Vankan et al., 2004823MOdontoid fracture type I & fracture through both atlantal pst archesC1, lt VA8 mos after traumaSudden upper & lower limb weakness & paresisCoil embolizationHalo brace followed by cervical collar1st halo, later dAVFNeurologically stable
Heuer et al., 2008923MBilat C2 pedicle & lat mass fracture toward transverse foramenC2, rt VA6 hrs after admissionDecreased strength lt upper & lower extremityEndovascular coiling proximally & distally to transectionHalo1st AVF, then fractureFull neurological symptom remission
Nishihiro et al., 20161066MC3 fracture toward transverse foramenC2, rt VAOn admission after traumaCervical bruitCoil embolizationConservative managementNAFull neurological symptom remission
Shiban & Meyer, 20181187FC5-C6 dislocation fractureThyrocervical trunk, rt VAImmediateParaparesis lower extremityNot fully treated due to fistula size & hemorrhagePst stabilization C3-C4-T10-T21st dissection (partially successful), then opDeath
Young et al., 20191255MC1-C4 pst cortex fracturesV2-V3, lt VADirectly at admissionGCS 3NBCA embolization of recipient vein & endovascular coiling ligation of VAOccipito-cervical stabilization1st AVF, then fracturePartial neurological symptom remission GCS 10
Zanin et al., 20201337FC2-C3 dislocation w/ retrolisthesis C2-C3C3, lt VAAt admissionNeck pain, paraparesis, impaired sensation lower body halfEndovascular embolization proximally & distally to rupture sitePst cervical decompression of C2-C71st AVF, then fractureFull neurological symptom remission
Andersen et al., 20211470MC1-C2 (lt facet, transverse foramen)-C3 fracturesC2, lt VADiagnosis 3 days afterNoneEndovascular coilingCervical collarNANo complications or other symptoms
Sarath Chander et al., 20211570MC2 pars fracture, C2-C3 disc disruptionC2, lt VADiagnosis on admissionNoneEndovascular coils (Amplatzer device, NBCA)C2-C3 ACDF1st AVF, then fractureFull neurological symptom remission
Karakoyun et al., 20221665MHangman’s fracture C2, C3 corpus, C1 anterior archC1-C3, lt V2-V3 segmentImmediateDirectly, weakness lt upper limb, tinnitus lt earEndovascular stent coilingPst stabilization C1 lat mass, C2 transpedicular, C3-C4 lat mass screws1st fracture, then AVFImproved neurological deficit, no complications

ACDF = anterior cervical discectomy and fusion; AVF = arteriovenous fistula; dAVF = dural arteriovenous fistula; GCS = Glasgow Coma Scale; NA = not applicable; NBCA = N-butyl cyanoacrylate; pst = posterior; VA = vertebral artery.

All but one case described AVFs diagnosed immediately at admission up until 3 days after trauma. One case described the occurrence of a symptomatic AVF 8 months after trauma. Nine of the 12 reported cases described endovascular treatment of the AVF with partial to full remission of symptoms. Open surgery was associated with partial recovery and death in two cases.

Fistulas involving the VA can be asymptomatic due to paired vessel perfusion compensation (Table 1; cases by Andersen et al.14 and Sarath Chander et al.15) or present with symptoms of vertebrobasilar insufficiency, including tinnitus (case by Karakoyun et al.16), vertigo, visual changes, ataxia, or lowered level of consciousness.1,12,17 Enlarged or aneurysmatic fistulas with vascular steal manifest as radiculopathy, neck and occipital pain, or myelopathy (Table 1; cases by Avellanosa et al.5 and Karakoyun et al.16). In all but one case, the dAVFs were diagnosed within a few hours to 3 days after admission. In one case, a dAVF developed 8 months after cervical spine trauma with the sudden onset of quadriplegia caused by an epidural hematoma at C1–C5 originating from a dAVF at the level of C1. In that case, however, one cannot exclude the presence of a dAVF at the time of trauma, as no angiography was performed initially. Our case features the rare, late development of a dAVF. The exact timing of the development of the dAVF, albeit delayed, is nonetheless unknown. The dAVF was not seen on the initial CTA at admission, and no CTA was performed at the 2-week follow-up when the patient remained asymptomatic. It is, however, clear that the patient developed symptoms of the dAVF at a delayed stage (i.e., 3 weeks after trauma). The initial VA injury was grade II (dissection with luminal narrowing) according to the Fassett classification, which progressed into a symptomatic grade V lesion (arteriovenous fistula [AVF]).17 Biffl et al.18 reported that the progression of VA injury occurred in 51% of their series of 97 patients with VA injury. Therefore, repeat CTA 7–10 days after initial diagnosis of a grade I or II VA injury is recommended.18 In our case, no cervical auscultation was performed, which could have raised the suspicion of an AVF before the development of clear symptoms and prompted earlier imaging and treatment.17

The preferred treatment of high-grade VA injuries including dAVFs is endovascular and may include the embolization of fistulas or aneurysms with or without balloon support or (flow-diverting) stent placement (Table 1).19–21 Ideally, the dAVF gets occluded with preservation of the parent vessel. In this case, the extensive dissection, proximal aneurysm formation, and high flow (as suggested by the absence of flow from the left VA to the posterior circulation) over the AVF necessitated parent vessel occlusion. The patient’s compromised cardiovascular status and preexistent occluded right ICA required great caution in sacrificing the left VA. Additional imaging of the right VA was therefore performed, demonstrating adequate flow to the posterior circulation and contralateral PICA (Fig. 4), thereby confirming that it was safe to perform segmental occlusion of the VA while preserving the PICA.

Lessons

This case reinforces that VA injury should be suspected in patients with a traumatic upper cervical spine fracture, especially in cases of a subluxation and involvement of the transverse foramen. VA injury can progress from a low-grade injury to a high-grade injury, thus necessitating follow-up angiography. Subsequent development of a (d)AVF can manifest shortly after cervical spine fracture, but our case demonstrates that late manifestation can also occur. In either case, complete obliteration of the dAVF is warranted, and endovascular embolization has been shown to be an effective treatment with high success rates. Finally, occlusion of the VA may be necessary for complete obliteration of the dAVF. Therefore, careful assessment of flow from the contralateral VA is required to confirm adequate perfusion of the posterior circulation.

Author Contributions

Conception and design: Schenck, Fodor, Haeren. Acquisition of data: Fodor, Wagemans. Analysis and interpretation of data: Fodor. Drafting of the article: Schenck, Fodor, Wagemans. Critically revising the article: all authors. Reviewed submitted version of the manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Schenck. Administrative/technical/material support: Wagemans. Study supervision: Haeren.

References

  • 1

    Kim YH, Gildenberg PL, Duchesneau PM. Angiographic evidence of spontaneous closure of nontraumatic arteriovenous fistula of the vertebral artery. Case report. J Neurosurg. 1973;38(5):658661.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Fusco MR, Harrigan MR. Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury. Neurosurgery. 2011;68(2):517530, discussion 530.

  • 3

    Miller PR, Fabian TC, Bee TK, et al. Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma. 2001;51(2):279285, discussion 285-286.

  • 4

    McCutcheon IE, Doppman JL, Oldfield EH. Microvascular anatomy of dural arteriovenous abnormalities of the spine: a microangiographic study. J Neurosurg. 1996;84(2):215220.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Avellanosa AM, Glasauer FE, Oh YS. Traumatic vertebral arteriovenous fistula associated with cervical spine fracture. J Trauma. 1977;17(11):885888.

  • 6

    Hayes P, Gerlock AJ Jr, Cobb CA. Cervical spine trauma: a cause of vertebral artery injury. J Trauma. 1980;20(10):904905.

  • 7

    Okuchi K, Fujioka M, Konobu T, et al. A case of Hangman’s fracture associated with vertebral arteriovenous fistula treated with trapping. Article in Japanese. No Shinkei Geka. 1994;22(1):5559.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Vankan Y, Demaerel P, Heye S, et al. Dural arteriovenous fistula as a late complication of upper cervical spine fracture. J Neurosurg Spine. 2004;100(suppl 4):382384.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Heuer GG, Gabel BC, Bhowmick DA, Stiefel MF, Hurst RW, Schuster JM. Symptomatic high-flow arteriovenous fistula after a C-2 fracture. Case report. J Neurosurg Spine. 2008;8(4):381384.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Nishihiro S, Sugiu K, Hishikawa T, et al. A case of traumatic vertebral arteriovenous fistula treated by internal trapping of the vertebral artery. Article in Japanese. No Shinkei Geka Neurol Surg. 2016;44(2):135141.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Shiban E, Meyer B. Traumatic vertebral artery rupture causing intraspinal hematoma and progressive neurological symptoms. Acta Neurochir (Wien). 2018;160(2):249251.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Young M, Johnson R, Gordhan A. Acute formation of a blunt trauma-induced vertebral artery arteriovenous fistula treated with endovascular occlusion of vertebral artery. Cureus. 2019;11(9):e5801.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Zanin L, Belotti F, Frigerio M, et al. Posttraumatic vertebral arteriovenous fistula: a lifeline from tetraplegia? World Neurosurg. 2020;142:413419.

  • 14

    Andersen MS, Krone W, Munthe S. Mild trauma causing cervical fracture through transverse foramen leading to a vertebral arteriovenous fistula. BMJ Case Rep. 2021;14(6):24.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Sarath Chander V, Govindasamy R, Rudrappa S, Gopal S. Unstable Hangman fracture complicated by vertebral-venous fistula: surgical considerations and review of literature. World Neurosurg. 2021;145:409415.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Karakoyun DO, Yılmaz A, Uzlu O, Dağlıoğlu E, Işık HS. Vertebral arteriovenous fistula due to blunt neck trauma: a case report. Article in Turkish. Ulus Travma Acil Cerrahi Derg. 2022;28(6):871875.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery injuries associated with cervical spine injuries: a review of the literature. J Spinal Disord Tech. 2008;21(4):252258.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Biffl WL, Ray CE Jr, Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg. 2002;235(5):699707.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Beaujeux RL, Reizine DC, Casasco A, et al. Endovascular treatment of vertebral arteriovenous fistula. Radiology. 1992;183(2):361367.

  • 20

    Waldman DL, Barquist E, Poynton FG, Numaguchi Y. Stent graft of a traumatic vertebral artery injury: case report. J Trauma. 1998;44(6):10941097.

  • 21

    Singer RJ, Dake MD, Norbash A, Abe T, Marcellus ML, Marks MP. Covered stent placement for neurovascular disease. AJNR Am J Neuroradiol. 1997;18(3):507509.

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  • FIG. 1

    Computed tomography (CT) scans of the cervical spine at admission. A: Axial CT scan of the cervical spine showing a Hangman’s fracture: a bilateral fracture through the pars interarticularis of C2 (red arrows). B: Axial CT scan of the cervical spine showing a fracture on the left side of the C2 body (red arrow). C: Axial CT scan of the cervical spine showing a fracture through the spinous process of C3 with a 7-mm diastasis (red arrow), classified as a type A0 according to the AO classification. D: Axial CT scan of the cervical spine showing the C2 fracture close to the left transverse foramen (red arrow). E: Sagittal CT scan of the cervical spine showing a 4-mm horizontal posterior displacement of the lamina of C2 (Hangman’s fracture type II based on the Levine and Edwards classification). F: Sagittal CT scan of the cervical spine showing a fracture involving the left C2–C3 facet (red arrow). AO = “Arbeitsgmeinschaft für Osteosynthesefragen” (AO Foundation).

  • FIG. 2

    CT angiography (CTA) of the cervical spine at admission (A) and 3 weeks after trauma (B–D). Axial CTA of the spine at admission (A), revealing a subtle contrast-filling defect of the left vertebral artery (VA) at the level of C2–C3 suggestive of a dissection of the VA (red arrow). Axial (B), sagittal (C), and coronal (D) CTA of the cervical spine 3 weeks after trauma, revealing a 9-mm aneurysmal dilation (red arrow) of the left VA at the level of C2–C3, and (dural) varicose veins (blue arrows).

  • FIG. 3

    Radiographs of the cervical spine at admission (A) and at follow-up (B–D). Lateral radiograph (A) of the cervical spine 1 day after trauma, showing the fracture through the pars interarticularis of C2 (red arrow) with dorsal displacement of the posterior complex of C2. Lateral radiograph (B) of the cervical spine 2 weeks after trauma, revealing a subtle angulation and increased distance of the lamina of C2 from the anterior complex of C2 (red arrow). Lateral radiograph (C) of the cervical spine 3 weeks after trauma, showing a further increased antero-position of C2 in relation to C3 (red arrow). Lateral radiograph (D) of the cervical spine 4 months after trauma and after embolization of the dural arteriovenous fistula (dAVF) at the level of C2–C3, revealing a correction of the antero-position of C2 relative to C3 (red arrow). The coils proximal and distal to the dAVF can also be noted (stars).

  • FIG. 4

    Digital subtraction angiography (DSA) of the left VA illustrating the dAVF. Lateral DSA (A) showing an aneurysmal dilation (red arrow) at the level of the left VA with early filling of ectatic veins (blue arrows). Coronal DSA (B) after contrast injection to the right VA showing filling of the left VA and the left posterior inferior cerebellar artery (PICA; yellow arrow), thereby confirming adequate collateral perfusion via the right VA. Coronal DSA (C) after contrast injection to the right VA showing flow from the right VA to the left VA with retrograde flow towards the dAVF (red arrow). Coronal view (D) after contrast injection to the right VA and following distal embolization of the dAVF, showing an absence of filling of the left VA, while flow to the left PICA (yellow arrow), is preserved.

  • 1

    Kim YH, Gildenberg PL, Duchesneau PM. Angiographic evidence of spontaneous closure of nontraumatic arteriovenous fistula of the vertebral artery. Case report. J Neurosurg. 1973;38(5):658661.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Fusco MR, Harrigan MR. Cerebrovascular dissections: a review. Part II: blunt cerebrovascular injury. Neurosurgery. 2011;68(2):517530, discussion 530.

  • 3

    Miller PR, Fabian TC, Bee TK, et al. Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma. 2001;51(2):279285, discussion 285-286.

  • 4

    McCutcheon IE, Doppman JL, Oldfield EH. Microvascular anatomy of dural arteriovenous abnormalities of the spine: a microangiographic study. J Neurosurg. 1996;84(2):215220.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Avellanosa AM, Glasauer FE, Oh YS. Traumatic vertebral arteriovenous fistula associated with cervical spine fracture. J Trauma. 1977;17(11):885888.

  • 6

    Hayes P, Gerlock AJ Jr, Cobb CA. Cervical spine trauma: a cause of vertebral artery injury. J Trauma. 1980;20(10):904905.

  • 7

    Okuchi K, Fujioka M, Konobu T, et al. A case of Hangman’s fracture associated with vertebral arteriovenous fistula treated with trapping. Article in Japanese. No Shinkei Geka. 1994;22(1):5559.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Vankan Y, Demaerel P, Heye S, et al. Dural arteriovenous fistula as a late complication of upper cervical spine fracture. J Neurosurg Spine. 2004;100(suppl 4):382384.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Heuer GG, Gabel BC, Bhowmick DA, Stiefel MF, Hurst RW, Schuster JM. Symptomatic high-flow arteriovenous fistula after a C-2 fracture. Case report. J Neurosurg Spine. 2008;8(4):381384.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Nishihiro S, Sugiu K, Hishikawa T, et al. A case of traumatic vertebral arteriovenous fistula treated by internal trapping of the vertebral artery. Article in Japanese. No Shinkei Geka Neurol Surg. 2016;44(2):135141.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Shiban E, Meyer B. Traumatic vertebral artery rupture causing intraspinal hematoma and progressive neurological symptoms. Acta Neurochir (Wien). 2018;160(2):249251.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Young M, Johnson R, Gordhan A. Acute formation of a blunt trauma-induced vertebral artery arteriovenous fistula treated with endovascular occlusion of vertebral artery. Cureus. 2019;11(9):e5801.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Zanin L, Belotti F, Frigerio M, et al. Posttraumatic vertebral arteriovenous fistula: a lifeline from tetraplegia? World Neurosurg. 2020;142:413419.

  • 14

    Andersen MS, Krone W, Munthe S. Mild trauma causing cervical fracture through transverse foramen leading to a vertebral arteriovenous fistula. BMJ Case Rep. 2021;14(6):24.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Sarath Chander V, Govindasamy R, Rudrappa S, Gopal S. Unstable Hangman fracture complicated by vertebral-venous fistula: surgical considerations and review of literature. World Neurosurg. 2021;145:409415.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Karakoyun DO, Yılmaz A, Uzlu O, Dağlıoğlu E, Işık HS. Vertebral arteriovenous fistula due to blunt neck trauma: a case report. Article in Turkish. Ulus Travma Acil Cerrahi Derg. 2022;28(6):871875.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Fassett DR, Dailey AT, Vaccaro AR. Vertebral artery injuries associated with cervical spine injuries: a review of the literature. J Spinal Disord Tech. 2008;21(4):252258.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Biffl WL, Ray CE Jr, Moore EE, et al. Treatment-related outcomes from blunt cerebrovascular injuries: importance of routine follow-up arteriography. Ann Surg. 2002;235(5):699707.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Beaujeux RL, Reizine DC, Casasco A, et al. Endovascular treatment of vertebral arteriovenous fistula. Radiology. 1992;183(2):361367.

  • 20

    Waldman DL, Barquist E, Poynton FG, Numaguchi Y. Stent graft of a traumatic vertebral artery injury: case report. J Trauma. 1998;44(6):10941097.

  • 21

    Singer RJ, Dake MD, Norbash A, Abe T, Marcellus ML, Marks MP. Covered stent placement for neurovascular disease. AJNR Am J Neuroradiol. 1997;18(3):507509.

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