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Background: We reviewed the clinical outcomes of a procedure that combines endovascular embolization and a direct surgical approach in a hybrid operating room (OR) for the treatment of refractory dural arteriovenous fistulas (dAVFs). Methods: All patients with intracranial dAVFs who underwent a procedure combining endovascular embolization and direct surgical approach with biplane angiography or a robotic C-arm system in a hybrid OR between February 2004 and June 2020 were considered. Borden grading, occlusion rate, pre-and post-operative modified Rankin Scale (mRS) scores, and complications were retrospectively investigated. The pre-and postoperative mRS scores were compared using the Wilcoxon signed-ranks test. Results: We evaluated 14 arteriovenous fistulas (AVFs) in consecutive 13 patients. Of these, ten AVFs were previously treated with endovascular embolization, ten were located in the transverse-sigmoid sinus, and four in the cortical vein. The Borden grade was II in two AVFs and III in 12 AVFs. Immediate occlusion of the AVF was achieved in 13 AVFs, and gradual occlusion was observed in one case. The median preoperative mRS was 1 (0–3), whereas the median postoperative mRS was 0 (0–1) which indicated marked improvement (P = 0.006). Complications including postoperative transient visual disturbance and intraprocedural extravasation were observed in only two cases. Conclusion: The combination of endovascular embolization and direct surgical approach in a hybrid OR could achieve sufficient occlusion of refractory AVFs with acceptable complication rates and improved symptoms.

Background: Intraosseous arteriovenous fistula (AVF) is a rare clinical entity that typically presents with symptoms from their effect on surrounding structures. Here, we report a case of intraosseous AVF in the sphenoid bone that presented with bilateral abducens palsy. Case Description: A previously healthy man presented with tinnitus for 1 month, and initial imaging suspected dural AVF of the cavernous sinus. Four-dimensional digital subtraction angiography (4D-DSA) imaging and a three-dimensional (3D) fused image from the bilateral external carotid arteries revealed that the shunt was in a large venous pouch within the sphenoid bone that was treated through transvenous coil embolization. His symptoms improved the day after surgery. Conclusion: This is a case presentation of intraosseous AVF in the sphenoid bone and highlights the importance of 4D-DSA and 3D fused images for planning the treatment strategy.

Foix-Alajouanine syndrome (FAS), also known as congestive myelopathy due to spinal vascular malformations, presents with paraplegia, sensory disturbance of lower limbs, and dysfunction of the bladder and rectum. Although FAS is characterized by a subacute onset of neurological symptoms that may wax and wane over a few years, the progression mechanism remains unclear. We report a case of FAS due to an angiographically occult arteriovenous fistula (AVF) that was diagnosed by an open surgical biopsy and intraoperative indocyanine green (ICG) angiography. The patient was a 74-year-old female who presented with a one-year history of gradually progressive gait disturbance, weakness, and decreased sensation in her legs associated with bladder and rectum dysfunction. MRI showed intramedullary T1 hypointensity, T2 hyperintensity at level Th4-12, and intramedullary enhancing with a Gd-DTPA lesion at level Th8-12. A true-FISP image of the MRI revealed an abnormal tortuous vessel in the dorsal spinal subarachnoid space, but digital subtraction angiography of the spine at the C1-L5 level showed no abnormality. The patient also underwent Th8-12 laminectomy for open biopsy. ICG angiography revealed blood flow stagnation in an abnormally enlarged posterior spinal vein. Histological findings indicated necrotizing myelopathy and stenosis with wall thickening of the posterior spinal vein. We hypothesized that the progression mechanism in the present case may have resulted from histological changes in the draining veins of an AVF. Intraoperative ICG angiography may be a valuable method, not only for diagnosing AVFs but also for determining the existence and pathological characteristics of FAS.