Surgical Management for Craniocervical Junction Arteriovenous Fistula Targeting the Intradural Feeder

BACKGROUND: Craniocervical junction arteriovenous fistula (CCJAVF) has a variety of forms, including dural and perimedullary arteriovenous fistulas. Owing to this anatomic variety, the terminologies for classifying CCJAVF, most of which aim to describe angiographic structures, have yet to be firmly established, and the current taxonomic classifications do not facilitate surgical strategies. Herein we focused on the existence of intradural feeder vessels, allowing the identification of 2 types of CCJAVF. This retrospective study aimed to assess the usefulness of our diagnostic classification for CCJAVF surgery. METHODS: We divided CCJAVF into 2 types: CCJAVF with an intradural feeder vessel and CCJAVF without an intradural feeder vessel. For the former type, we set the surgical goal of interrupting the intradural feeder and the draining veins behind the posterior spinal nerve. For the latter type, the surgical goal was to interrupt the draining veins behind the posterior spinal nerve. We retrospectively analyzed the outcomes of our surgical cases. RESULTS: Of 12 patients with CCJAVF, 8 underwent direct surgery. No patients showed exacerbation of neurological symptoms after surgery. One patient needed a second operation for residual shunt, and another patient developed an asymptomatic angiographic recurrence in the epidural space detected on follow-up imaging. The overall outcomes of surgical cases were good with an average modified Rankin Scale score of 1.0. CONCLUSIONS: Our results indicate that our diagnostic classification for CCJAVF has the potential to simplify CCJAVF treatment without compromising patient outcomes.