Case of a high flow A-V shunt associated with an extracranial vertebral-artery dissecting aneurysm treated with a flow diverter stent

Vertebrovenous fistula (VV-AVF) is a rare disease that is often caused by trauma, but occasionally associated with congenital anomalies. To date, no standardized treatment has been established, and the use of a flow diverter (FD) has been reported in only one case. A 59-year-old woman had received chiropractic treatment that focused on her neck 1 month prior to symptom onset. She subsequently developed headaches and bilateral tinnitus. MRI and cerebral angiography revealed that demonstrated a dissection of the right vertebral artery (VA) at the level of the transverse foramen of C6, resulting in a dissecting aneurysm with no distal flow visualized. In addition, at the same level, a fistula formed with the surrounding venous plexus, and blood drained into multiple jugular veins. We decided to use FD to cover the dissecting aneurysm and close the fistula as treatment. However, due to persistent early shunt flow, a transvenous coil embolization was additionally performed. One week later, follow-up angiography confirmed restoration of antegrade flow in the VA and complete obliteration of the fistula. The use of FD in combination with VV-AVF may result in rapidly improve normal perfusion, whereas the combination of FD and Trans venous embolization (TVE) has been shown to have an even more rapid therapeutic effect. To our knowledge, this is the first reported case on FD + TVE, although its effectiveness has been demonstrated in this case.