Management of Aneurysms and AVMs at the Cranio-vertebral Junction

A wide range of diseases can involve the foramen magnum and cranial-vertebral junction (CVJ). Among them, vascular cases represent infrequent pathologies when compared with development disorders, trauma, and tumors. In spite of this, different vascular pathologies can occur at the CVJ, like posterior circulation aneurysms (saccular or fusiform/dissecting vertebral artery—posterior inferior cerebellar artery aneurysms and distal posterior inferior cerebellar artery aneurysms), arteriovenous malformations at the medulla oblongata or cervico-medullary junction and dural arteriovenous fistulas (DAVFs) of foramen magnum, hypoglossal canal, jugular foramen, marginal sinus and cervico-medullary junction. Surgery, endovascular treatment, and radiosurgery are all considered as treatment options for vascular diseases at the CVJ. Nevertheless, considering possible complications deriving from different treatment strategies, a multidisciplinary team evaluation is required. When surgical treatment is preferred, different approaches directed toward the CVJ can be used, e.g., midline suboccipital or far-lateral approach with or without extension to the high cervical region. Thus, total knowledge of CVJ neurovascular anatomy and good surgical exposure are both mandatory to reduce cranial nerves manipulation during surgical maneuvers. The exact location of the pathology and regional anatomy strictly influence surgical and clinical outcome. In this chapter, we review the technical nuances of approaches and surgical outcomes for aneurysm and arteriovenous malformations (including dural AVFs) of this region.