Successful management of a giant spinal arteriovenous malformation with multiple communications between primitive arterial and venous structures by embolization: report of a case

Partially trombosed glomus type spinal arteriovenous malformation – case presentation

Spinal AVM are very rare vascular lesions and most o the studies give reports on only a few cases. Given their localization between the spinal tracts and the gray matter core of the medulla and their multiple feeders from posterior and anterior spinal arteries they are amongst the most difficult surgical pathology in the nervous sistem. We present the case of a 60 years old male with a glomus type T10-L2 spinal AVM that presented with motor deficit in the lower limbs and urinary incontinence. The partially thrombosed lesion was completely resected without previous embolisation, and the patient was walking with assistance at discharge. This is a rare case that presented with progressive neurological deterioration consistent with an ischemic rather than a hemorrhagic event. Microsurgery is a better option than conservative treatment in these rare cases of spontaneous occlusion of intramedullary arteriovenous malformations.

Spinal glomus-type arteriovenous malformations: microsurgical treatment in 20 cases

Object

Glomus-type spinal arteriovenous malformations (AVMs) are rare. In the literature only small series and anecdotal reports can be found, and there are no prospective series elucidating the natural course or the superiority of 1 treatment regimen over another (such as surgery versus embolization versus conservative treatment). Microsurgical treatment of spinal AVMs often seems difficult because many lesions are not anatomically suitable for primary microsurgical occlusion and are therefore treated with first-line neuroradiological interventions or not at all.

Methods

Between 1989 and 2005, 20 patients with glomus-type AVMs underwent microsurgical treatment at 2 major neurosurgical centers in Germany. The history of symptoms in these patients ranged from 2 days to 11 years. Four patients presented with subarachnoid hemorrhage, 2 with intramedullary hematoma, 4 with paresthesia or pain, and 10 with clinical signs of myelopathy. Seven patients underwent partial embolization prior to microsurgery. The authors only operated on AVMs accessible from a dorsal or dorsolateral approach. Neurological status was assessed with the McCormick classification scheme. Follow-up data were obtained from outpatient records. Three patients were interviewed over the telephone and 4 patients were not available for follow-up evaluation.

Results

Surgery was performed via a laminectomy in 14 and hemilaminectomy in 6 patients. The microsurgical technique used consisted of retrograde dissection of the AVM from the venous side in most cases. Four (20%) of 20 patients showed worsening of neurological symptoms to a worse McCormick grade, probably caused by suspected venous stasis directly after surgery, however only 1 patient (5%) suffered permanent deterioration after surgery. In 14 patients postoperative angiography proved complete occlusion in 11 patients, including the presence of a remnant requiring a second operation with complete occlusion thereafter in 1 patient. In 3 patients occlusion was incomplete: a small residual AVM remained in 1 patient, and a discrete feeding vessel without a vein was evident in 2 patients.

Conclusions

Spinal cord AVMs are rare. If embolization is not possible, surgery may be indicated in selected cases. Spinal AVMs behave differently after incomplete occlusion either surgically or with embolization. A postoperative reduction in symptoms is frequent despite the presence of small remnants, and the risk of neurological deficits seems relatively low even in residual AVMs. Therefore, treatment need not necessarily aim at complete occlusion if that would be associated with an unacceptably high risk of neurological deficits.

Intraparenchymal brain hemorrhage and remote soft tissue arteriovenous malformation in a newborn infant

Congenital arteriovenous malformations (AVMs) often present with congestive heart failure. Such pathologic vascular structures typically occur in cranial, hepatic, or pulmonary locations and are usually associated with overlying external visible, tactile, or audible abnormalities. These vascular anomalies may also be associated with such complications as thromboembolic events, coagulopathy, and localized hemorrhage. We present a newborn infant with an occult but hemodynamically significant parascapular AVM who presented with an intraparenchymal brain hemorrhage, which we suspect to be a remote complication of the AVM.

Anaesthesia for interventional neuroradiology

Neuroradiologists have extended their treatment modalities in the field of vascular neurosurgery. The rapidly emerging and re-engineered neuroradiological techniques confront the anaesthetist with an increasing number of patients with severe neurological disease. More of these patients will need general anaesthesia in order to facilitate the endovascular procedure, including catheter placement, deposition of embolic material, and improved imaging. Anaesthetists are challenged by additional anaesthesiological aspects previously not encountered in neuroanaesthesia. A safe anaesthetic management is based on a broad understanding of pathophysiological and technical issues that arise with the endovascular treatment of cerebral vasculopathy.

Multiple gigantic arteriovenous malformations with destruction of lumbar vertebral bodies. A case report

STUDY DESIGN

This case report describes a patient with massive intramuscular and paravertebral arteriovenous malformations with destruction of vertebral bodies.

OBJECTIVES

To demonstrate successful interbody fusion of the involved vertebral bodies after embolization for arteriovenous malformation.

SUMMARY OF BACKGROUND DATA

Although arteriovenous malformations in the spinal cord are well documented in the literature, arteriovenous malformation in the paravertebral and iliopsoas muscles with destruction of vertebral bodies is an extremely rare clinical condition.

METHODS

After careful investigation with angiography, the arteriovenous malformations were managed with embolization, and the scoliosis caused by the collapsed vertebral bodies was managed surgically by anterior spinal fusion with segmental spinal instrumentation.

RESULTS

The patient's scoliosis caused by vertebral collapse was corrected by surgery, and good alignment of the lumbar spine was achieved. The preoperation pain had subsided completely by follow-up assessment 1 year and 10 months after fusion. However, the arteriovenous malformations still remained. Careful observation should be maintained continuously in the coming days.

CONCLUSION

In arteriovenous malformations with destruction of the vertebral bodies, embolization and spinal fusion with segmental instrumentation may be necessary to relieve pain and prevent the progression of spinal deformity. Arteriovenous malformation should be considered in the diagnostic evaluation of a patient who has experienced vertebral collapse with no inflammatory signs.