High-Flow Vertebral Artery Fistula Eroding the Vertebral Body

Introduction: Vertebral arteriovenous fistulas (VAVF) are communicating openings between vertebral arteries and a muscular branch or epidural venous plexus. Progression of VAVFs most commonly manifests as pulsatile tinnitus, neck pain, radiculopathy, and pulsatile bruits ipsilateral to the VAVF. Bony erosion secondary to VAVF is a rare occurrence that is not well-described in the literature. Here, we present the first report of a VAVF with erosion of the vertebral foramen and associated vertebral body that was treated endovascularly.

Methods: A retrospective review was conducted and patient data including medical records and imaging studies were analyzed.

Results: A 56-year-old female presented to the emergency department after an episode of syncope. Subsequent work-up ruled out seizure. Catheter angiography revealed a prominent, high-flow fistula involving the cervical right vertebral artery. Eloquent venous structures were spared, but bony erosion of the vertebral foramen was evident. Two months later, the patient returned with escalating episodes of near syncope and lightheadedness, in addition to progressively increasing headaches and stumbling. MRI, MRA, and cerebral angiography revealed enlargement of the right VAVF, spanning from C1 to C3, with approximately 50% erosion of the right lateral C3 vertebral body. Given the progression of both the patient’s symptoms and VAVF on imaging, the decision was made to undergo endovascular embolization of the fistula via coiling. Angiograms demonstrated complete occlusion of the fistula and the patient tolerated the procedure with no neurologic setback. Follow-up catheter angiogram will be performed 6 months from the time of treatment.

Conclusion : To our knowledge, this study is the first report of a high-flow VAVF causing erosion of a vertebral body that was successfully treated endovascularly. Understanding the spectrum of symptomatology in patients with VAVF and the potential progression of VAVF over time is critical to both the diagnosis and management of these rare lesions.