The shunt point of the sacral dural arteriovenous fistula: a case report and literature review.

The occurrence of sacral dural arteriovenous fistula (dAVF) is rare. The detailed vascular architecture of sacral dAVF, including three-dimensional (3D) angiographic images with operative findings, has not been evaluated compared to that of the thoracic and lumbar levels. We report a case of sacral dAVF with 3D angiographic examination and operative findings, with a literature review.

A 60-year-old man presented with progressive urinary incontinence and gait disturbance. A sacral dAVF was detected at the S1/2 level. The shunt point was at the medial side of the line between the intermediate sacral crest and the most medial point of the L5 pedicle circle at the anterior posterior view of the angiography; we defined this type as the medial type. After the embolization, latent inflow arteries were visualized ipsilaterally and contralaterally. During surgery, due to dAVF recurrence, a vascular tangle was found on the dura. The surgical interruption of the draining vein improved the patient's symptoms. From the literature review, 92% of cases had medial type shunt point. It is possible for sacral dAVF to have multiple inflow arteries originated ipsilaterally or bilaterally, and a venous pouch.

The shunt point of sacral dAVF tended to be located medially, not in the sacral foramen. Sacral dAVF has unique angioarchitecture. The differentiation of dAVF from epidural arteriovenous fistula may not be easy in some cases of sacral lesions. Thus, further studies with a larger number of patients focused on the detailed vascular architecture are needed.

World neurosurgery. 2020 Feb 14 [Epub ahead of print]

Kenji Takahashi, Yoshihisa Matsumoto, Yui Nagata, Takuro Hashikawa, Hideki Sakai, Keiichiro Furuta, Hidenobu Yoshitake, Setsuko Nakagawa, Yoshihisa Fukushima

Department of Neurosurgery, St. Mary's Hospital., Department of Neurosurgery, St. Mary's Hospital. Electronic address: ., Department of cerebrovascular medicine, St. Mary's Hospital.