Pediatric spontaneous vertebro-venous fistula coil occlusion with vertebral artery preservation and distal vertebral artery flow restoration

BACKGROUND: Vertebro-venous fistula (VVF) is a rare high-flow arteriovenous shunt between the vertebral artery and the surrounding venous plexus. Spontaneous VVF in the pediatric population is exceptionally uncommon. Prior pediatric reports have demonstrated successful endovascular fistula occlusion with preservation of vertebral artery patency, although the reported experience remains limited. OBSERVATIONS: A 9-year-old boy presented with an 8-month history of progressive cervical and upper thoracic pain without neurological deficit. MRI demonstrated a left suboccipital vascular lesion with bilateral vertebral artery enlargement and diminution of the distal left vertebral artery. Digital subtraction angiography confirmed a high-flow direct arteriovenous fistula at the V3 segment with a large venous pouch and absence of V4 visualization. Endovascular coil embolization achieved marked reduction in fistula flow with immediate restoration of V4 segment visualization. Follow-up angiography confirmed complete obliteration without residual shunting. LESSONS: Spontaneous pediatric VVF can be successfully treated by precise fistula-point coil occlusion with vertebral artery preservation. Timely and complete endovascular fistula obliteration can restore distal vertebral artery visualization while preserving the parent artery. This illustrates the potential reversibility of flow-related angiographic abnormalities in high-flow VVF.