Foramen magnum dural arteriovenous fistula presenting with epilepsy

Area of Science:

• Neurology
• Neurosurgery
• Radiology

Background:

• Intracranial dural arteriovenous fistulas (dAVFs) with perimedullary drainage are rare.
• They typically cause progressive myelopathy or brainstem signs.

Observation:

• A patient presented with an atypical foramen magnum dAVF, initially exhibiting a generalized tonic-clonic seizure without myelopathy.
• One month later, the patient developed rapidly progressive tetraplegia and respiratory insufficiency.
• Venous drainage was complex, involving both the temporal lobe and perimedullary veins (Type III+V), leading to congestion and edema.

Findings:

• Rotational angiography and MRI overlays were crucial for visualizing the complex fistula anatomy.
• Endovascular embolization was performed as treatment.
• Post-embolization imaging showed complete remission of venous congestion.

Implications:

• This case highlights an unusual presentation of a craniocervical junction fistula with epilepsy as the initial symptom.
• It underscores the importance of considering dAVFs in patients with unexplained neurological deficits, even without typical myelopathy.
• The findings emphasize the utility of advanced imaging techniques in diagnosing and managing complex dAVFs.