History: Liu Moumou, female, 9 years old. She was admitted to the hospital on July 25, 2015 for “headache and nausea for 1 day”. History: the patient in the afternoon of July 24, 2015 at 13 o’clock began without obvious causes suddenly appeared headache, crying, accompanied by nausea, about 5 minutes after the patient’s state of mind into a coma, urinary incontinence, no convulsions, immediately by the family to the local people’s hospital, on the way the patient has been in a comatose state, call out, spit out white foamy sputum in the mouth twice. In the local hospital, the patient’s mental state turned clear, but still felt a severe headache, after perfecting the cranial CT, due to the seriousness and complexity of the condition, he was transferred to our hospital for further treatment in the morning of July 25th Liu Lei, Department of Neurosurgery, Beijing 301 Hospital, Physical Examination: mental state is clear, spirit is general, painful face, orientation is normal, comprehension is normal, judgment is normal, computation is normal. Bilateral pupils were equal in size and round, with a diameter of about 2.5mm and sensitive to light reflex. There was no eyelid ptosis, the eye slits were equal in width, the eyeballs were not sunken, and the eyeballs moved freely in all directions. Motor: normal muscle volume of the limbs, no muscle atrophy, no muscle bundle tremor, upper limb muscle strength grade V, lower limb muscle strength grade V, normal muscle tone. Pathologic signs were not elicited. Right facial paralysis, left limb hemiparesis, muscle strength grade 2-3, positive pathologic signs. Auxiliary examinations: cranial CT (07/25/2015, our hospital): 1. Increased density shadow in the left basal ganglia area and temporal lobe, consider: vascular lesion, enhancement examination is recommended. 2. Intraventricular hemorrhage. Cranial CTA (07/25/2015, our hospital): 1, left internal carotid artery-middle cerebral artery junction segment high-flow malformed vessel with formation of arteriovenous fistula. 2, cervical intravertebral canal malformed vessel, distal and vertebral artery intracranial segment traffic, proximal drainage pathway is poorly shown. Preliminary diagnosis: 1, intracranial vascular malformation with hemorrhage. 2, Cervical intravertebral vascular malformation. Treatment process: On 2015-7-27, whole brain angiography was performed, suggesting cerebral arteriovenous fistula in the M1 segment of the left middle cerebral artery and cervical medullary arteriovenous malformation. Under emergency general anesthesia, cerebral arteriovenous fistula balloon-assisted spring coil + ONYX gel embolization and cervical medullary arteriovenous malformation embolization were performed. The imaging and treatment process was as follows: after the success of general anesthesia, the patient took the flat position, and the routine disinfection and laying of towels. Through the right femoral artery puncture placed 4F tube sheath for cerebral angiography, the left internal carotid artery angiography arterial phase to see the beginning of the cerebral middle M1 appeared venous bulb developed, to the left side of the transverse sinus drainage, consider the arteriovenous fistula; at the same time, see the right side of the anterior circulation through the anterior traffic to the leakage of the mouth of the blood supply, the blood flow of blood flow through the ipsilateral back of the traffic to the leakage of the mouth of the blood supply of the left side of the anterior cerebral artery branch through the anastomotic branch, the left side of the cerebral middle M1 segment to the leakage of the mouth of the blood supply of the same. The left vertebral artery angiography showed abnormal mass staining of the spinal cord vessels in the cervical segment, and the blood-supplying artery was the posterior spinal artery branching out from the left vertebral artery. After the diagnosis was clear, the 6F sheath was exchanged, and the introducer catheter was placed at the level of the left internal carotid artery at the level of the 1st vertebral body of the flat neck through the multifunctional catheter, and the Hyperform low-tension balloon was sent to the fistula opening through the guidance of microguide wire, and then the microcatheter was carefully sent to the venous bulb inside the fistula opening with guidance of the microguide wire, and then the balloon was flushed out of the fistula opening, and after the blood flow was reduced significantly, the NEXUS3D was sent through the microcatheter to the venous bulb inside the fistula opening. Six spring coils (10/30mm, 9/30mm, 8/30mm, 6/20mm, 4/12mm, 3/8mm) were inserted into the fistula and the venous bulb through the microcatheter and the Onyx gel was injected into the fistula and the venous bulb, and the arteriovenous fistula disappeared from the follow-up imaging, and there were no abnormal changes in the other blood vessels in the cranium. The Hyperform low-tension balloon was sent to the proximal end of the posterior spinal artery (spinal vascular malformation blood-supplying artery) emanating from the V4 segment of the left vertebral artery under the guidance of a microguide wire, and the microcatheter Echlon-10 was carefully placed into the blood-supplying artery of the spinal vascular malformation (posterior spinal artery) with the guidance of a microguide wire, and the Hyperform balloon was flushed up, and the blood flow was significantly reduced, and the Onyx gel was injected into the fistula and venous bulb through the microcatheter. Echlon-10 was injected into the Onyx gel, and review of the imaging showed that the abnormal blood supply disappeared and the malformed mass was not visualized. The operation was completed. Intraoperative bleeding was 30 ml, anesthesia was satisfactory, and the patient returned safely to the monitoring room. The patient recovered smoothly after the operation. He was awake and extubated. He was discharged 10 days after surgery. At the time of discharge, the right facial paralysis was grade 1, and the left limb muscle strength was grade 4. Discussion: 1. Vascular malformations of the central nervous system in children are rare, 0.014-0.028%, and this case is a middle cerebral artery arteriovenous fistula, combined with cervical cord arteriovenous malformation. The most common clinical manifestations of vascular malformations are hemorrhage and epilepsy, which in our patient presented as hemorrhage. The recurrence rate of vascular malformation in children is high, and the prognosis is better after active treatment of hemorrhage. 2, vascular malformation treatment: ① observation: for asymptomatic, not ruptured, and large vascular malformation can be used in observation. ② Surgery: for Spetzler-Martin classification 1-3 patients surgical patients benefit. ③Interventional therapy: the rate of complete disappearance of vascular malformation is only 5-10%. Radiotherapy: the disappearance rate in 2-5 years is related to the size of vascular malformation, 75-95% for <75px malformed vessels, <70% for >75px malformed vessels. This patient is a middle cerebral artery arteriovenous fistula, high blood flow surgery is not desirable. Interventional therapy is a very good method, which has been proved to be perfect. Spinal vascular malformation is also not suitable for surgery. Interventional therapy is satisfactory. 3, interventional therapy application method: ① low tension balloon assisted: in the process of embolization of arteriovenous fistula, through the use of low tension balloon, reduce the local malformation of the high blood flow power of the blood vessels, so that the spring coil is placed in a satisfactory way, otherwise the spring coil into the blue difficulties. In the process of spinal arteriovenous malformation embolization, through the use of low-tension balloon, to reduce the local malformation blood flow velocity of the blood supply artery, so that the Onyx gel release rate is controllable, to avoid excessive embolization, damage to the spinal cord. At the same time, it prevents the glue from flowing backward to the vertebral artery. ② Combined application of spring coil and Onyx gel: spring coil alone can also be used to embolize the arteriovenous fistula, but the coil dosage is large, the cost is large, and there is a risk of displacement of the spring coil. The consequences are serious. Combined spring coil and Onyx glue, first make the spring coil into blue, and then Onyx glue dense filling into blue spring coil, so that the embolism firmly and stably embolized fistula, no displacement. Under the assistance of balloon, the rubber ring is well shaped, and the middle cerebral artery conformity, no stenosis and residual neck, the treatment is satisfactory. 4, experience: a variety of auxiliary means in endovascular intervention has been widely used. Embolization safety can be increased by reducing local blood flow. The combined application of multiple embolic substances can increase the stability of embolization and make up for their respective deficiencies. In order to achieve the best embolization effect.