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While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery. [ABSTRACT FROM AUTHOR]

Background: Dural arteriovenous fistulas (DAVF) complicate intracranial hemorrhages that are secondary to cortical venous reflux (CVR). Clinicians usually pay attention to CVR but not to other uncommon etiologies in hemorrhagic cases. Here, we report the rare case of a ruptured pial feeder aneurysm arising from the posterior inferior cerebellar artery (PICA) that was successfully treated with endovascular surgery. Case description: An 81-year-old man was transferred to the emergency department of our hospital because of sudden onset of vertigo and vomiting. Head computed tomography showed a hyperdense area of up to 2.6 cm in the cerebellar vermis, intraventricular hemorrhage in the fourth ventricle, and subarachnoid hemorrhage in the cerebellopontine cistern. Digital subtraction angiography (DSA) showed a torcular DAVF. CVR was observed in the bilateral cerebellar veins (Borden type 3, Cognard type 4). DSA revealed a small aneurysm in the vermian branch of the left PICA feeding the DAVF. Because the aneurysm was arising from the vermian branch itself, we decided to occlude it with 12.5% N-butyl-2-cyanoacrylate. The vermian branch harboring the aneurysm was successfully obliterated. Rebleeding did not occur postoperatively. Conclusions: The CVR is a common etiology of intracranial hemorrhage caused by DAVF. However, clinicians should be aware that the pial feeder may also contribute to hemorrhagic complications. Our case illustrates the significance of the existence of the pial feeder in hemorrhagic DAVF and the potential contribution of an aneurysm arising from the pial feeder to the etiology. Care should be taken not to overlook the pial feeder on radiologic imaging, and appropriate surgical management should be performed to prevent rupture.

Arteriovenous fistulas at the craniocervical junction are rare vascular malformations with frequent hemorrhagic presentations, which may have a concurrent pial feeder aneurysm. A 65-year-old man presented with subarachnoid hemorrhage and angiography showed an epidural arteriovenous fistula at the C-2 level with an anterior spinal feeder aneurysm without perimedullary venous drainage. Transarterial coil embolization of the ruptured aneurysm and partial Onyx embolization of the shunt led to thrombosis of the aneurysm. However, three years later angiography showed an increased shunt flow and recurrence of the aneurysm. Transvenous embolization of the shunt using coils and Onyx yielded complete obliteration of the shunt, thus leading to occlusion of the aneurysm. This case demonstrates that partial transarterial embolization of arteriovenous fistula leaves a risk of rebleeding, whereas complete obliteration of the shunt with a transvenous approach can lead to disappearance of the flow-related aneurysm without embolization of the aneurysm itself. [ABSTRACT FROM AUTHOR]