====== Vertebrojugular fistula ====== ===== Etiologies ===== ● Iatrogenic e.g., during [[spine surgery]] or [[angiography]], [[chiropractic manipulation]], nerve block injection or radiation therapy ((Sancak T, Bilgic S, Ustuner E. Endovascular stent-graft treatment of a traumatic vertebral artery pseudoaneurysm and vertebrojugular fistula. Kore- an J Radiol. 2008; 9 Suppl:S68–S72)) ((Nagashima C, Iwasaki T, Kawanuma S, Sakaguchi A, Kamisasa A, Suzuki K. Traumatic arteriovenous fis- tula of the vertebral artery with spinal cord symp- toms. Case report. JNeurosurg. 1977; 46:681–687)). ● [[Trauma]] e.g.,penetrating injury, or [[Gunshot wound]] ● [[Vasculitis]] ---- Vertebrojugular fistulas have been described in the literature associated with blunt or penetrating injury and iatrogenic or spontaneous development. Its presentation may be broad and may include symptoms of radiculopathy, vertebrobasilar insufficiency, tinnitus, and bruit. ---- The gold standard for diagnosis is digital subtraction angiography (DSA). Doppler ultrasonography, magnetic resonance-angiography and computerized tomography-angiography are also helpful ===== Endovascular management of VJF ===== Stenting. A polytetrafluoroethylene (PTFE) covered stent, e.g., Jostent, may be used to cover the ostia of the fistula ((Sancak T, Bilgic S, Ustuner E. Endovascular stent-graft treatment of a traumatic vertebral artery pseudoaneurysm and vertebrojugular fistula. Kore- an J Radiol. 2008; 9 Suppl:S68–S72)). Coil occlusion. In the presence of adequate blood flow through contralateral healthy vertebral artery, the fistulous artery may be occluded with coils ((O'Shaughnessy BA, Bendok BR, Parkinson RJ, Shaibani A, Batjer HH. Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report. Surg Neurol. 2005; 64:335–40; discussion 340)) Verify that the arterial wall with the fistulous connection is part of the occluded segment. NBCA occlusion. Rarely, NBCA occlusion has been performed when stenting or coils occlusion were not possible ((Jayaraman MV, Do HM, Marks MP. Treatment of traumatic cervical arteriovenous fistulas with N- butyl-2-cyanoacrylate. AJNR Am J Neuroradiol. 2007; 28:352–354)). [[Onyx]] may also be used similarly. ===== Case reports ===== A case of an 86-year-old female who suffered a C5 vertebral fracture secondary to a ground-level fall that was initially treated conservatively due to the onset of new severe atrial fibrillation. However, the patient was later on taken to surgery due to progressive neurologic deterioration. Intraoperative complications led to the diagnosis of a vertebral-jugular fistula that was successfully embolized. The effective obliteration of the fistulae led to the recovery of both neurologic and cardiac symptoms ((Saavedra-Pozo F, Vicenty-Padilla J, Rodriguez-Mercado R. A rare case of a vertebrojugular arteriovenous fistula: A case report and review of literature. J Craniovertebr Junction Spine. 2017 Jul-Sep;8(3):268-270. doi: 10.4103/jcvjs.JCVJS_49_17. PubMed PMID: 29021679; PubMed Central PMCID: PMC5634114. )). ---- A case with sharp bread knife injury of the vertebral artery that was also complicated with a vertebrojugular fistula and pseudo-aneurysm ((Yilmaz MB, Donmez H, Tonge M, Senol S, Tekiner A. Vertebrojugular arteriovenous fistula and pseudoaneurysm formation due to penetrating vertebral artery injury: case report and review of the literature. Turk Neurosurg. 2015;25(1):141-5. doi: 10.5137/1019-5149.JTN.8247-13.1. PubMed PMID: 25640560. )). ---- A case of a fistula between the [[vertebral artery]] and the [[internal jugular vein]] that occurred after the erroneous placement of a [[central venous catheter]]. The patient was presented with [[tinnitus]]. Endovascular treatment with a balloon expandable covered stent placed into the vertebral artery was performed. One year follow-up showed satisfactory exclusion of the fistula, patency of the stented vertebral artery, and resolution of the symptoms. Only few other similar cases are reported in the literature with the use of different types of stents ((Nikolopoulos P, Krokidis M, Spiliopoulos S, Lioupis C, Gkoutzios P, Katsanos K, Ahmed I, Sabharwal T. Endovascular treatment of an iatrogenic vertebrojugular fistula with a balloon-expandable covered stent: case report and review of the literature. Perspect Vasc Surg Endovasc Ther. 2012 Sep;24(3):149-54. doi: 10.1177/1531003513482735. Epub 2013 Mar 28. Review. PubMed PMID: 23538994. )). ---- Vertebrojugular fistula mimicking an intradural schwannoma ((Gürer B, Dilli A, Sanli AM, Yildirim UM, Kertmen H. Vertebrojugular fistula mimicking an intradural schwannoma. Clin Neurol Neurosurg. 2013 Apr;115(4):468-71. doi: 10.1016/j.clineuro.2012.05.035. Epub 2012 Jun 26. PubMed PMID: 22738733.)). ---- Two patients presenting with the carotid blowout syndrome and one patient with a vertebrojugular fistula were treated with covered stents. This allowed for preservation of the vessel and was a treatment alternative to cerebral bypass. Covered stents provide a viable means of preserving the cervical vessels in selected patients; however, long-term follow-up is necessary to determine stent patency and permanency of hemostasis ((Alaraj A, Wallace A, Amin-Hanjani S, Charbel FT, Aletich V. Endovascular implantation of covered stents in the extracranial carotid and vertebral arteries: Case series and review of the literature. Surg Neurol Int. 2011;2:67. doi: 10.4103/2152-7806.81725. Epub 2011 May 28. PubMed PMID: 21697983; PubMed Central PMCID: PMC3115199. )). ---- A patient with a chronic, symptomatic V2 segment vertebrojugular fistula was successfully treated with a vertebral artery stent graft, with immediate tinnitus resolution. No early or late complications were observed, and at 45 months of follow-up, the patient remains asymptomatic with a patent stent graft ((Girn HR, McPherson SJ, Allan C. Vertebral artery stent graft for a chronic symptomatic vertebrojugular arteriovenous fistula. J Vasc Surg. 2009 Jun;49(6):1570-3. doi: 10.1016/j.jvs.2009.01.002. Review. PubMed PMID: 19497521. )). ===== References =====