C3 dAVF: Unusual Ischemic Presentation

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Cervical spinal dural arteriovenous fistulas extremely rarely present with multiple ischemic episodes. This is a 54 year old female who presented with at least two or three small brain stem strokes. The initial strokes were managed medically. However, their recurrence led to further evaluation, including an angiogram, which demonstrated a C3 dural arteriovenous fistula. You can see the later phase of the lateral cervical spine angiogram showing the draining vein along the midline. Patient subsequently underwent cervical laminectomy. You can see the right side of the spinal cord at the level of the C3 the arachnoid veins were dissected and the C3 nerve root was identified. The dentate ligament was disconnected. Here is the C3 nerve root. Inspection just anterior to the roots revealed this small dural arteriovenous fistula located at the level of this foramen. Here is the arterialized vein. Inspection of the nerve roots above and below this level did not reveal any other abnormality. Here's the C2 nerve root. An ICG angiogram confirmed the arterialized vein, which filled very early during the time of injection. I was convinced that the pathology has been found. A temporary clip was placed across the fistula's connection as close to the C3 foramen as possible. The fistulas connections were all coagulated and subsequently transected. Another ICG revealed no evidence of an arterialized vein. I felt that the pathology has been found and adequately addressed and postoperative angiogram demonstrated exclusion of the dural arteriovenous fistula and this patient did not suffer from any new episodes of ischemia and made an excellent recovery. Thank you.

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