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Chen KS, Williams DD, Iacobas I, McClugage SG, Gadgil N, Kan P. Spontaneous thrombosis of high flow pediatric arteriovenous fistulae: Case series of two patients and a comprehensive literature review. Childs Nerv Syst 2024; 40:1405-1414. [PMID: 38085366 DOI: 10.1007/s00381-023-06241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/21/2023] [Indexed: 04/19/2024]
Abstract
Pediatric pial arteriovenous shunts in the brain and spine are challenging to understand because of low incidence, variable presentation, and associations with genetic syndromes. What is known about their natural history comes from reviews of small series. To better understand the natural history and role for intervention, two cases are presented followed by a review of the literature. In the first case, an infant with a prior history of intracranial hemorrhage from a ruptured pial fistula returns for elective embolization for a second pial fistula which was found to be spontaneously thrombosed 2 weeks later. In the second case, a 5-year-old with a vertebro-vertebral fistula, identified on work up for a heart murmur and documented with diagnostic angiography, is brought for elective embolization 6 weeks later where spontaneous thrombosis is identified. In reviewing the literature on pediatric single-hole fistulae of the brain and spine, the authors offer some morphologic considerations for identifying which high-flow fistulae may undergo spontaneous thrombosis to decrease the potentially unnecessary risk associated with interventions in small children.
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Affiliation(s)
- Karen S Chen
- Edward B. Singleton Department of Radiology and Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX, 77030, USA.
| | - Daniel Davila Williams
- Department of Neurology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 1250, Houston, TX, 77030, USA
| | - Ionela Iacobas
- Department of Pediatrics, Baylor College of Medicine, Vascular Anomalies Center at Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, 6701 Fannin St, Suite 1510, Houston, TX, 77030, USA
| | - Samuel G McClugage
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 1230, Houston, TX, 77030, USA
| | - Nisha Gadgil
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 1230, Houston, TX, 77030, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, 1005 Harborside Dr, 5th floor, Galveston, TX, 77555, USA
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2
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Reynolds CD, Caton MT, Baker A, Smith ER, Amans MR, Cooke DL, Dowd CF, Higashida RT, Gupta N, Abla AA, Auguste K, Fox CH, Fullerton H, Hetts SW. Clarifying the clinical landscape of pediatric spinal arteriovenous shunts: an institutional experience and individual patient-data meta-analysis. J Neurointerv Surg 2023; 16:94-100. [PMID: 36922033 DOI: 10.1136/jnis-2022-019797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Pediatric spinal arteriovenous shunts (SAVS) are rare lesions with heterogeneous pathogenesis and clinical manifestations. OBJECTIVE To evaluate the clinical characteristics, angioarchitecture, and technical/clinical outcomes in SAVS through a large single-center cohort analysis and meta-analysis of individual patient data. METHODS A retrospective institutional database identified children (aged 0-21 years) who underwent digital subtraction spinal angiography (DSA) for SAVS between January 1996 and July 2021. Clinical data were recorded to evaluate angioarchitecture, generate modified Aminoff-Logue gait disturbance scores (AL) and McCormick grades (MC), and assess outcomes. We then performed a systematic literature review following PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for individual patient data) guidelines, extracting similar data on individual patients for meta-analysis. RESULTS The cohort consisted of 28 children (M:F=11:17) with 32 SAVS lesions, with a mean age of 12.8±1.1 years at diagnosis. At presentation, SAVS were most highly concentrated in the cervical region (40.6%). Children had a median AL=2 and MC=2, with thoracolumbar AVS carrying the greatest disability. Among treated cases, complete obliteration was achieved in 48% of cases and median AL scores and MC grades both improved by one point. Systematic literature review identified 161 children (M:F=96:65) with 166 SAVS lesions with a mean age of 8.7±0.4 years. Among studies describing symptom chronicity, 37/51 (72.5%) of children presented acutely. At presentation, children had a median AL=4 and MC=3, with thoracolumbar AVS carrying the highest MC grades. After intervention, median AL and MC both improved by one point. CONCLUSIONS This study provides epidemiologic information on the location, onset, and presentation of the full spectrum of pediatric SAVS, highlighting the role of targeted treatment of high-risk features.
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Affiliation(s)
- Conner D Reynolds
- Department of Medical Imaging, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - M Travis Caton
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric R Smith
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kurtis Auguste
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christine H Fox
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather Fullerton
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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3
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Essibayi MA, Srinivasan VM, Catapano JS, Graffeo CS, Lawton MT. Spinal Dorsal Intradural Arteriovenous Fistulas: Natural History, Imaging, and Management. Neurology 2023; 101:524-535. [PMID: 37185123 PMCID: PMC10516273 DOI: 10.1212/wnl.0000000000207327] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 03/06/2023] [Indexed: 05/17/2023] Open
Abstract
In this review, we describe the pathophysiology, diagnosis, and treatment of spinal dorsal intradural arteriovenous fistulas (DI-AVFs), focusing on novel research areas. DI-AVFs compose the most common subgroup of spinal arteriovenous lesions and most commonly involve the thoracic spine, followed by lumbar and sacral segments. The pathogenesis underlying DI-AVFs is an area of emerging understanding, thought to be attributable to venous congestion and hypertension that precipitate ascending myelopathy. Patients with DI-AVFs typically present with motor, sensory, or urinary dysfunction, although a wide swath of other less common symptoms has been reported. DI-AVFs can be subdivided by spinal region, which in turn is associated with 4 distinct clinical phenotypes: craniocervical junction (CCJ), subaxial cervical, thoracic, and lumbosacral. Patients with CCJ and lumbosacral DI-AVFs have particularly interesting presentations and treatment considerations. High-value diagnostic findings on MRI include flow voids, missing-piece sign, and T2-weighted intramedullary hyperintensity. However, digital subtraction angiography is the gold standard for diagnosis and localization of DI-AVFs and for definitive treatment planning. Surgical disconnection of DI-AVFs is almost universally curative and frontline treatment, especially for CCJ and lumbosacral DI-AVFs. Endovascular techniques evolve in promising ways, such as improved visualization, distal access, and liquid embolic techniques. The pathophysiology of DI-AVFs is better understood using newly identified radiologic diagnostic markers. Despite new techniques and devices introduced in the endovascular field, surgery remains the gold-standard treatment for DI-AVFs.
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Affiliation(s)
- Muhammed Amir Essibayi
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Visish M Srinivasan
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Joshua S Catapano
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Christopher S Graffeo
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Michael T Lawton
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ.
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4
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Almawi AS, Alhammad AS, Alshammari ZA, Althubait S, Alqahtani S. Salvageable Intra-stent Coil Embolization Treatment for Spinal Dural Arteriovenous Fistula in a Child. Cureus 2023; 15:e42425. [PMID: 37637553 PMCID: PMC10448778 DOI: 10.7759/cureus.42425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Spinal dural arteriovenous fistulae (SDAVF) are rare diseases that exhibit abnormal connections between arteries and veins. They are even rarer in the pediatric population and pose diagnostic and treatment challenges for physicians. Its presentation varies depending on the site and size of the SDAVF. Multiple management options are available, which are usually tailored depending on the patient's condition. Here, we present a rare case of SDAF in a four-year-old girl who initially presented with bilateral lower limb weakness. The patient was then treated successfully using primary major fistula point stenting and intra-stent coiling, with complete closure achieved. Full recovery was achieved over the course of follow-ups. The deep analysis of SDAVF, its classification, and the utilization of the best available endovascular tools by a dedicated neurovascular team offer the best outcome in dealing with complex spinal neurovascular pathologies.
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Affiliation(s)
| | | | | | - Shorog Althubait
- Interventional Neuroradiology, King Fahad Medical City, Riyadh, SAU
| | - Sultan Alqahtani
- Interventional Neuroradiology, King Fahad Medical City, Riyadh, SAU
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5
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Yu J, Zhang S, Bian L, He C, Ye M, Li G, Hu P, Sun L, Ling F, Zhang H, Hong T. Clinical features and outcomes of perimedullary arteriovenous fistulas: comparison between micro- and macro-type lesions. J Neurointerv Surg 2022:neurintsurg-2021-018412. [PMID: 35732484 DOI: 10.1136/neurintsurg-2021-018412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/03/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Although the angioarchitecture of perimedullary arteriovenous fistulas (PMAVFs) is straightforward, their size and blood flow are highly heterogeneous. This study aimed to evaluate the differences in clinical features and outcomes of PMAVFs based on lesion size and blood flow. METHODS 114 consecutive patients with PMAVFs from two institutes were retrospectively reviewed. The lesions were classified as either micro-PMAVFs (shunt point diameter <1 cm) or macro-PMAVFs (shunt point diameter ≥1 cm). RESULTS The patients with micro-PMAVFs were older at the first presentation (33.50 vs 13.50 years, p<0.001). Macro-PMAVFs were more commonly associated with spinal metameric arteriovenous shunts (6.9% vs 28.6%, p=0.003). Compared with the macro-PMAVFs, the micro-PMAVFs showed a significantly higher risk of gradual clinical deterioration after initial onset (73.6%/year vs 10.0%/year; HR 3.888, 95% CI 1.802 to 8.390, p=0.001). A total of 58.6% of the micro-PMAVFs were treated surgically, whereas 85.7% of the macro-PMAVFs were treated via endovascular approaches. Complete obliteration was 73.7% for the whole cohort, and was more common for the micro-PMAVFs than for the macro-PMAVFs (87.9% vs 58.9%, p=0.001). At the last follow-up, spinal function was significantly improved compared with the pretreatment status, and the rate of severe disability of patients with macro-PMAVFs was slightly but not significantly higher than that of patients with micro-PMAVFs (16.1% vs 8.6%, p=0.315) CONCLUSIONS: The clinical risks, treatment strategies and obliteration rates of PMAVFs differ based on their size and blood flow.
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Affiliation(s)
- Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Shiju Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | | | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China .,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China .,China International Neuroscience Institute (China-INI), Beijing, China
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6
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Nicholson P, Krings T. Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00069-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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7
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Abstract
Spinal cord diseases in pediatric patients are highly variable in terms of presentation, pathology, and prognosis. Not only do they differ with respect to each other but so too with their adult equivalents. Some of the most common diseases are autoimmune (ie, multiple sclerosis, acute disseminated encephalomyelitis, and acute transverse myelitis), congenital (ie, dysraphism with spina bifida, split cord malformation, and tethered cord syndrome), tumor (ie, juvenile pilocytic astrocytoma, ependymoma, and hem-angioblastoma), and vascular (ie, cavernous malformations, arteriovenous malformations, and dural arteriovenous fistulas) in nature. These each require their own niche treatment paradigm and prognosis. Furthermore, presentation of different spinal cord diseases in children can be difficult to discern without epidemiologic and imaging data. Interpretation of these data is crucial to facilitating a timely and accurate diagnosis. Correspondingly, the aim of this review was to highlight the most pertinent features of the most common spinal cord diseases in the pediatric population.
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Affiliation(s)
- Victor M Lu
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL.,Department of Neurological Surgery, University of Miami, Miami, FL
| | - Toba N Niazi
- Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, FL.,Department of Neurological Surgery, University of Miami, Miami, FL
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8
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Yu JX, He C, Ye M, Li GL, Bian LS, Yang F, Zhai XD, Ling F, Zhang HQ, Hong T. The efficacy and deficiency of contemporary treatment for spinal cord arteriovenous shunts. Brain 2021; 144:3381-3391. [PMID: 34156437 DOI: 10.1093/brain/awab237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/15/2021] [Accepted: 06/03/2021] [Indexed: 11/12/2022] Open
Abstract
Contemporary treatments for spinal cord arteriovenous shunts are only based on clinicians' treatment experiences and expertise due to its rarity. We reviewed the clinical course of the largest multi-cantered cohort to evaluate the efficacy and deficiency of contemporary interventional treatments for spinal cord arteriovenous shunts. The clinical features, treatment results and clinical outcomes of 463 spinal cord arteriovenous shunts patients were retrospectively assessed. The main outcome was the neurological deterioration that was evaluated based on the modified Aminoff and Logue scale. According to post-treatment DSA, complete obliteration was defined as disappearance of the intradural lesion, whereas partial obliteration was defined as any residual intradural lesion remaining visible and was further categorized as shunt-reduction obliteration (the nidus or shunt points was reduced) or palliative obliteration (only obliterated aneurysms or feeders). Cure rate was 40.6% for whole cohort, 58.5% after microsurgery, and 26.4% after embolization. The curative resection was associated with non-metameric lesions, lesions with a maximum diameter < 3 cm and lesions without anterior sulcal artery supply. The curative embolization was associated with fistula-type lesions, non-metameric lesions, and main drainage diameter < 1.5 mm. Permanent treatment-related neurological deficits rate was 11.2% for the whole cohort, 16.1% after microsurgery, and 5.6% after embolization. The pre-treatment clinical deterioration rate was 32.5%/year, which decreased to 9.3%/year after clinical interventions. After partial treatment, the long-term acute and gradual deterioration rate were 5.3%/year and 3.6%/year, respectively. The acute deteriorations were associated with metameric lesions, craniocervical lesions, lesions with a maximum diameter ≥2 cm and residual aneurysm. Residual aneurysm was the only predictor of acute deterioration for non-metameric spinal cord arteriovenous shunts. The gradual deteriorations were associated with palliative obliteration, absence of pre-treatment acute deterioration and intact main drainage. Although clinical risks of spinal cord arteriovenous shunts were reduced after clinical interventions, contemporary treatments for spinal cord arteriovenous shunt remains associated with considerable risks and incomplete efficacy. Individualized treatment plans should be adopted according to the angioarchitectural features and major clinical risks of specific lesions. There is a higher opportunity for complete obliteration for lesions with simple angioarchitecture. However, regarding most of spinal cord arteriovenous shunts with complex vascular anatomy, partial treatment is the only choice. For these patients, palliative obliteration targeting the aneurysms is recommended for reducing hemorrhagic risk, whereas shunt-reduction obliteration is necessary for non-haemorrhagic myelopathy. Contemporary treatment is ineffective in reducing hemorrhagic risk of incurable metameric spinal cord arteriovenous shunts.
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Affiliation(s)
- Jia-Xing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Gui-Lin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Li-Song Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Xiao-Dong Zhai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Hong-Qi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
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Baldassarre B, Balestrino A, D'Andrea A, Anania P, Ceraudo M, Truffelli M, Melloni I, Mavilio N, Castellan L, Zona G, Fiaschi P. Management of spinal aneurysms associated with arteriovenous malformations: systematic literature review and illustrative case. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2767-2774. [PMID: 34043050 DOI: 10.1007/s00586-021-06881-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 01/29/2021] [Accepted: 05/13/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Spinal aneurysms are rare vascular malformations, commonly associated with spinal AVMs. AVM-associated spinal aneurysms are burdened by significant morbidity. The purpose of our study is to evaluate the best treatment strategy for these uncommon vascular lesions and to report an illustrative case. METHODS We reviewed clinical and radiological data of a patient surgically treated at our institution for a spinal AVM with an associated prenidal aneurysm. According to PRISMA guidelines, a systematic literature review has been performed in order to discuss the best management AVM-associated prenidal aneurysms. RESULTS In the reported case, the aneurysm showed spontaneous regression at follow-up after surgical removal of the AVM. Only 6 articles reported management of spinal prenidal AVM-associated aneurysms. Basing on our experience and data from literature, surgical treatment of the aneurysm may be indicated along with the resection of the AVM if the aneurysm is close to the nidus. Conversely, if the aneurysm is far away from the nidus or in an unfavorable position, resection of the nidus only may lead to aneurysm regression as in the reported case. CONCLUSIONS The treatment strategy for AVM-associated spinal aneurysms should be tailored on the single patient. In presence of large aneurysms that cause mass-effect symptoms, when rupture of the aneurysm is suspected or when treatment of the AVM is not proposable, direct treatment of the aneurysm should be considered. Otherwise, when complete resection of the nidus is performed, the eventually associated unruptured aneurysms located in challenging positions can be safely managed conservatively.
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Affiliation(s)
- Bianca Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Alberto Balestrino
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Alessandro D'Andrea
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Pasquale Anania
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Marco Ceraudo
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Monica Truffelli
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Ilaria Melloni
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Nicola Mavilio
- Department of Diagnostic and Interventional Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lucio Castellan
- Department of Diagnostic and Interventional Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluigi Zona
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
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10
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Consoli A, Coskun O, Di Maria F, Gratieux J, Condette-Auliac S, Smadja S, Boulin A, Rodesch G. Spinal cord arterio-venous shunts: From classification to therapeutic management. Rev Neurol (Paris) 2021; 177:469-476. [PMID: 33781564 DOI: 10.1016/j.neurol.2021.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/24/2022]
Abstract
Spinal Cord Arterio-Venous shunts (SCAVSs) are a rare disease. The aim of this paper is to describe how we classify and consider management of SCAVSs in relation to the location of the shunt focusing mainly on intradural SCAVSs. The anatomical features of the SCAVSs together with data provided by MRI and CT scans allow identification of four types of SCAVSs: paraspinal, epidural, dural and intradural ones. Clinical and neuroradiologic characteristics are described for each entity as well as the therapeutic endovascular management at our institution between 2002 and 2020. The therapeutic management of SCAVSs, and in particular of intradural shunts, remains mainly based on endovascular treatment as a first-choice approach. Understanding properly the lesional and regional vascular anatomy is mandatory to plan an appropriate therapeutic strategy and obtain good clinical results stable at long term follow up.
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Affiliation(s)
- A Consoli
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France.
| | - O Coskun
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - F Di Maria
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - J Gratieux
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - S Condette-Auliac
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - S Smadja
- Interventional Neuroradiology, Fondation Rotschild Hospital, 29, rue Manin, 75019 Paris, France
| | - A Boulin
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - G Rodesch
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
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Mizutani K, Rodesch G. Anatomical disposition of the anterior spinal artery and vein: Subpial or subarachnoid? Interv Neuroradiol 2020; 26:706-707. [DOI: 10.1177/1591019920928628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Katsuhiro Mizutani
- Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
- Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga, Japan
| | - Georges Rodesch
- Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
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Rajadurai J, Kohan S, Wenderoth J. Management of spinal dural arteriovenous fistula in a child with myelopathy. Surg Neurol Int 2020; 11:91. [PMID: 32494372 PMCID: PMC7265422 DOI: 10.25259/sni_33_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/20/2020] [Indexed: 11/04/2022] Open
Abstract
Background:
Spinal dural arteriovenous fistulas (DAVF) are rare intradural spinal lesions. Patients with DAVF are typically in the 40’s or 50’s, and classically present with acute neurological deterioration. Notably, these lesions are exceedingly rare in the pediatric age group.
Case Description:
A 2-year-old child presented with the sudden onset of lethargy, and 4/5 weakness of the left lower extremity with accompanying ataxia. The cervicothoracic MR scan revealed central cord edema from C5 to T4. A DAVF was diagnosed based on the multiple dilated intradural perimedullary veins. Following endovascular treatment, the child markedly recovered and remained stable 2 years later.
Conclusion:
DAVFs are treatable lesions that rarely occur in the pediatric age group. They are associated with serious neurological morbidity. When suspected, they should be immediately diagnosed with magnetic resonance imaging/magnetic resonance angiography, and formal angiography. Prompt neurosurgical and neuroradiological/ endovascular opinions and intervention should be sought to provide and the best treatment strategy.
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Affiliation(s)
- Jeremy Rajadurai
- Departments of Neurosurgery, Sydney Childrens Hospital, Randwick, New South Wales, Australia
| | - Saeed Kohan
- Departments of Neurosurgery, Sydney Childrens Hospital, Randwick, New South Wales, Australia
| | - Jason Wenderoth
- Departments of Interventional Neuroradiology, Sydney Childrens Hospital, Randwick, New South Wales, Australia
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Brinjikji W, Colombo E, Lanzino G. Clinical and angioarchitectural characteristics of spinal vascular malformations of the cervical spine. J Neurosurg Spine 2020; 32:755-762. [PMID: 31952038 DOI: 10.3171/2019.11.spine19798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vascular malformations of the cervical spine are exceedingly rare. To date there have been no large case series describing the clinical presentation and angioarchitectural characteristics of cervical spine vascular malformations. The authors report their institutional case series on cervical spine vascular malformations diagnosed and treated at their institution. METHODS The authors retrospectively reviewed all patients with spinal vascular malformations from their institution from January 2001 to December 2018. Patients with vascular malformations of the cervical spine were included. Lesions were characterized by their angioarchitectural characteristics by an interventional neuroradiologist and endovascular neurosurgeon. Data were collected on clinical presentation, imaging findings, treatment outcomes, and long-term follow-up. Descriptive statistics are reported. RESULTS Of a total of 213 patients with spinal vascular malformations, 27 (12.7%) had vascular malformations in the cervical spine. The mean patient age was 46.1 ± 21.9 years and 16 (59.3%) were male. The most common presentations were lower-extremity weakness (13 patients, 48.1%), tetraparesis (8 patients, 29.6%), and lower-extremity sensory dysfunction (7 patients, 25.9%). Nine patients (33.3%) presented with hemorrhage. Fifteen patients (55.6%) had modified Rankin Scale scores of 0-2 at the time of diagnosis. Regarding angioarchitectural characteristics, 8 patients (29.6%) had intramedullary arteriovenous malformations (AVMs), 5 (18.5%) had epidural arteriovenous fistulas (AVFs), 4 (14.8%) had paraspinal fistulas, 4 (14.8%) had mixed epidural/intradural fistulas, 3 (11.1%) had perimedullary AVMs, 2 (7.4%) had dural fistulas, and 1 patient (3.7%) had a perimedullary AVF. CONCLUSIONS This retrospective study of 27 patients with cervical spine vascular malformations is the largest series to date on these lesions. The authors found substantial angioarchitectural heterogeneity with the most common types being intramedullary AVMs followed by epidural AVFs, paraspinal fistulas, and mixed intradural/extradural fistulas. Angioarchitecture dictated the clinical presentation as intradural shunts were more likely to present with hemorrhage and acute onset myelopathy, while dural and extradural shunts presented as either incidental lesions or gradually progressive congestive myelopathy.
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Affiliation(s)
- Waleed Brinjikji
- Departments of1Neurosurgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Giuseppe Lanzino
- Departments of1Neurosurgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
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Brinjikji W, Ahn ES, Patterson MC, Lanzino G. Challenging dogma: report of a spinal cord arteriovenous malformation as an acquired lesion in a pediatric patient. J Neurosurg Spine 2020; 32:302-304. [PMID: 31653811 DOI: 10.3171/2019.7.spine19253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/12/2019] [Indexed: 11/06/2022]
Abstract
Spinal cord intramedullary arteriovenous malformations (AVMs) have classically been considered congenital lesions that are present from birth. The reason for this dogmatic principal is the fact that a vast majority of these lesions present in pediatric and young adult patients. Interestingly, while many authors have demonstrated the development of de novo nidus-type brain AVMs, there have been no reported cases of a de novo intramedullary or perimedullary AVM of the spine. In this paper the authors describe what they believe to be the first reported case of a de novo AVM of the spinal cord in a young patient who underwent serial imaging from birth for evaluation of a syrinx. Potential pathophysiological mechanisms for the development of de novo vascular malformations of the spinal cord are discussed.
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15
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Yu JX, Hong T, Krings T, He C, Ye M, Sun LY, Zhai XD, Xiang SS, Ma YJ, Bian LS, Ren J, Tao PY, Li JW, Yang F, Li GL, Ling F, Zhang HQ. Natural history of spinal cord arteriovenous shunts: an observational study. Brain 2019; 142:2265-2275. [PMID: 31211368 DOI: 10.1093/brain/awz153] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 03/28/2019] [Accepted: 04/15/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
The natural history of intradural spinal cord arteriovenous shunts is unknown. We performed an observational study in a consecutive patient cohort with symptomatic intradural spinal cord arteriovenous shunts who were admitted to three institutes to investigate the clinical course of this complex disease, which would provide valuable evidence to inform clinical decision-making. The clinical course of patients with symptomatic intradural spinal cord arteriovenous shunts from initial presentation to occurrence of clinical deterioration, initiation of treatment, or last follow-up was analysed. Patients with at least 1 month of observation were included in this study. Clinical onset and deterioration patterns were divided into acute and gradual. Annual and cumulative rates of clinical deterioration as well as their risk factors were analysed using Kaplan-Meier life table analysis and Cox proportional hazards model. To assess risks and benefits of treatment, post-treatment clinical courses were further assessed. Four hundred and sixty-six patients with a mean observational period of 36.9 ± 58.8 months were included; 56.7% of patients presented with acute onset, of whom 77.3% experienced spontaneous recovery. Age of onset older than 28 years, initial modified Aminoff and Logue scale of >3, mid-thoracic lesions and non-ventral lesions were independent predictors of failure for spontaneous recovery. The annual risk of general, acute and gradual clinical deterioration after onset was 30.7%, 9.9% and 17.7%, respectively. Risk of deterioration was highest in the early period after initial onset. Acute onset was the only independent risk factor [hazard ratio 1.957 (95% confidence interval, CI 1.324–2.894); P = 0.0008] of acute deterioration and gradual onset was the strongest predictor [hazard ratio 2.350 (95% CI 1.711–3.229); P < 0.0001] of the gradual deterioration among all the stratifying factors. After invasive treatment, complete obliteration was achieved in 37.9% of patients (138 of 364) and improved or stable clinical status was noted in 80.8% of patients. Forty-two patients (11.5%) experienced permanent complications. Overall post-treatment deterioration rate was 8.4%/year, and 5.3%/year if permanent complications were excluded. The natural history of symptomatic spinal cord arteriovenous shunts is poor, especially in the early period after onset, and early intervention is thus recommended. Initial onset pattern significantly affects the natural history of the lesion, which prompts a differentiated treatment strategy.
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Affiliation(s)
- Jia-Xing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Timo Krings
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, Toronto, Canada
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Li-Yong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Xiao-Dong Zhai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Si-Shi Xiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Yong-Jie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Li-Song Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Peng-Yu Tao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Jing-Wei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Gui-Lin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
| | - Hong-Qi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- International Neuroscience Institute (China-INI), Beijing, China
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Intradural spinal cord arteriovenous shunts in the pediatric population: natural history, endovascular management, and follow-up. Childs Nerv Syst 2019; 35:945-955. [PMID: 30843101 DOI: 10.1007/s00381-019-04108-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Intradural spinal cord arteriovenous shunts represent a rare entity, particularly in the pediatric population, and clinical diagnosis can be challenging. METHODS We report the analysis of clinical, angioarchitectural, procedural, and follow-up data in a population of 36 children managed by our team between 2002 and 2017. RESULTS Hemorrhage occurred in 26 children (72%). Age at onset was 9.22 ± 3.65 years. Lesions were located at the thoracic level in 16 cases, at the cervical level in 15 cases, and the thoraco-lumbar region in 5 cases. A genetic or metameric syndrome was associated in 18 children (50%). Glue embolization provided complete occlusion in 5 children, subtotal in 7, and extensive in 14 without intraprocedural complications. We observed clinical normalization in 11 children, improvement in 11 cases, and stability in 3. Four children worsened during the follow-up, and one child died. CONCLUSIONS Endovascular staged glue embolization performed in experienced centers is safe in the treatment of pediatric intradural spinal cord arteriovenous shunts. Clinical and neuroradiological follow-up is mandatory, especially for pediatric patients.
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Xiang Y, Dai L, Yuan J, Zhu J, Deng C. Effects of P38/MAPK pathway on cognitive function and inflammation in rats with cerebral small vascular disease. Panminerva Med 2019; 62:273-275. [PMID: 31146514 DOI: 10.23736/s0031-0808.19.03647-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Yong Xiang
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Li Dai
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Junlan Yuan
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Jianping Zhu
- Department of Nephrology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Deng
- Department of Neurology, Renmin Hospital, Hubei University of Medicine, Shiyan, China -
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Li J, Zeng G, Zhi X, Bian L, Yang F, Du J, Ling F, Zhang H. Pediatric perimedullary arteriovenous fistula: clinical features and endovascular treatments. J Neurointerv Surg 2018; 11:411-415. [DOI: 10.1136/neurintsurg-2018-014184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 11/04/2022]
Abstract
ObjectivePediatric spinal perimedullary arteriovenous fistula (PMAVF) is rare but may cause permanent disability. We aim to summarize the clinical features of pediatric PMAVFs and our clinical experience in their treatment and to evaluate the effect of endovascular treatment in a large cohort.MethodsFrom 2008 to 2017, 51 PMAVFs in pediatric patients (<14 years' old) treated with endovascular techniques were retrospectively reviewed, including 24 type IVb (47.1%) and 27 type IVc (52.9%) lesions. Clinical features, radiological findings, treatment, and outcomes were evaluated.ResultsThirty-eight boys and thirteen girls were included, and the mean age at presentation was 5.6±4.1 years. Acute neurological deterioration was identified in 33 patients, and 21 of those patients (63.6%) suffered from bleeding. The annual bleeding rate before treatment was 2.55%. After transarterial embolization with coils and glue, 46 PMAVFs (90.2%) were completely occluded, and five (9.8%) were obliterated by supplementary microsurgery. During a follow-up period of 6 to 119 months (mean 58.4±16.7 months), the patients’ clinical states were improved in 42 cases (82.4%), stationary in nine cases (17.6%), and aggravated in none. Type IVc patients had a longer preoperative period, more chronic symptoms, a lower cure rate by embolization, and less improvement of symptoms than type IVb patients had (P<0.05).ConclusionsPediatric PMAVF is a special subgroup of intradural arteriovenous shunt that should be treated early. Endovascular embolization is safe and effective in the treatment of pediatric PMAVFs.
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Extending Endovascular Embolization to Type A Spinal Perimedullary Arteriovenous Fistula Using Liquid Embolic Agent: Technical Nuances, Challenges and Initial Outcome. World Neurosurg 2018; 119:267-273. [PMID: 30118864 DOI: 10.1016/j.wneu.2018.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The definitive treatment of perimedullary arteriovenous fistulas (PMAVFs) is warranted in view of the progressive neurologic decline noted with the conservative mode of management. The treatment options include microsurgical excision, endovascular embolization, or a multimodal approach. Because of the relatively larger size of the feeding arteries in type B and C PMAVFs, an endovascular approach is usually feasible. However, the endovascular treatment for type A lesions is technically challenging in view of near normal sized arterial feeders. Endovascular embolization using n-butyl cyanoacrylate is described; however, successful use of liquid embolic agents such as onyx or squid is not previously documented. CASE DESCRIPTION The described 3 cases initially presented with insidious onset and gradually progressive paraparesis, paresthesia, and urinary symptoms. The imaging (magnetic resonance and digital subtraction angiography) revealed type A PMAVFs. The microcatheter could be successfully navigated close to the fistulous site, and complete obliteration of the fistula was achieved using ethylene vinyl alcohol copolymer (EVOH)-based liquid embolic agent, squid in all of our cases. The occlusion remained durable, and patients showed steady neurologic improvement in the follow-up period. CONCLUSIONS Endovascular embolization of type A PMAVF using EVOH-based liquid embolic agent is feasible and could be considered as an effective alternative to surgery.
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20
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Jung SC, Song Y, Cho SH, Kim J, Noh SY, Lee SH, Sheen JJ, Rhim SC, Jeon SR, Suh DC. Endovascular management of aneurysms associated with spinal arteriovenous malformations. J Neurointerv Surg 2017. [DOI: 10.1136/neurintsurg-2017-013150] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BackgroundSpinal aneurysms are rare among spinal arteriovenous malformations (SAVMs). There are few reports of endovascular management of spinal aneurysms associated with SAVM.ObjectiveTo present endovascular management of aneurysms associated with SAVM.MethodsOf 91 patients with SAVMs,eight (9%) presented with aneurysms. Of these, three were male and five were female with a median age of 18 years (range 11–38). We evaluated the presenting pattern, lesion level, type of the target aneurysm related to the presenting pattern and AVM nidus, and the result obtained after embolization or open surgery. Clinical status was evaluated by Aminoff–Logue (ALS) gait and micturition scale scores.ResultsThe presenting patterns were subarachnoid hemorrhage (SAH, n=3) or mass effect caused by extrinsic (n=4) or intrinsic (n=1) cord compression. Aneurysms were located in four cervical, two thoracic, and two lumbar enlargement areas. There were two prenidal (arterial), three nidal, and three postnidal (venous) aneurysms. The mean diameter of the aneurysms was 9 mm (range 3–27). Glue embolization (n=6), open surgery (n=1), and combined surgery and embolization (n=1) was performed to obliterate the aneurysms. Obliteration of the target aneurysms resulted in improvement of symptoms and clinical stabilization of SAVMs in all patients during a mean of 55 months (range 7–228) of follow-up.ConclusionsIdentification of a symptomatic aneurysm should be associated with clinical presentation pattern. Targeted obliteration of the aneurysm by embolization and/or surgery resulted in improvement of symptoms and stabilization of SAVM.
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Roccatagliata L, Kominami S, Krajina A, Sellar R, Soderman M, Van den Berg R, Desal H, Condette-Auliac S, Rodesch G. Spinal cord arteriovenous shunts of the ventral (anterior) sulcus: anatomical, clinical, and therapeutic considerations. Neuroradiology 2017; 59:289-296. [DOI: 10.1007/s00234-017-1789-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/18/2017] [Indexed: 10/20/2022]
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Brinjikji W, Lanzino G. Endovascular treatment of spinal arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:161-174. [PMID: 28552139 DOI: 10.1016/b978-0-444-63640-9.00016-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Spinal arteriovenous malformations (AVMs) are a rare but treatable cause of myelopathy and spinal cord hemorrhage. The clinical presentation and ideal treatment of these lesions vary widely, primarily due to differences in anatomic and angioarchitectural features. Six well-defined types of fistula have been defined: (1) intradural dorsal AVM; (2) intramedullary AVM; (3) extradural-intradural AVM; (4) intradural ventral AVF; (5) extradural/epidural AVF; and (6) conus medullaris AVM. Each of these lesions have unique clinical presentations and variable natural histories and endovascular treatment options. The principles of endovascular treatment include: (1) a complete understanding of the angioarchitecture and anatomic features of the lesion, including identification of radiculomedullary arteries; (2) careful spinal angiography; (3) identification of treatment goals prior to the procedure (i.e., complete occlusion versus partial occlusion aimed at altering natural history); (4) selection of proper embolic agent; and (5) careful follow-up in both the immediate postoperative setting and long term.
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Hong T, Park JE, Ling F, terBrugge KG, Tymianski M, Zhang HQ, Krings T. Comparison of 3 Different Types of Spinal Arteriovenous Shunts below the Conus in Clinical Presentation, Radiologic Findings, and Outcomes. AJNR Am J Neuroradiol 2016; 38:403-409. [PMID: 27884878 DOI: 10.3174/ajnr.a5001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/06/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal arteriovenous shunts below the conus constitute 3 types of lesions, which have previously been mainly described in case reports, given their rarity, and are sometimes misdiagnosed. The purpose of this study was to describe the features of each type and compare these types as to epidemiologic features, clinical and radiologic presentations, treatment, and outcomes in a consecutive series of 48 cases. MATERIALS AND METHODS The prospectively collected data bases of 2 referral centers for spinal vascular lesions were retrospectively reviewed. Spinal arteriovenous shunts below the conus were defined as all dural and intradural shunts below the conus medullaris. Clinical features, radiologic findings, treatment results, and clinical outcomes were assessed. RESULTS There were filum terminale arteriovenous fistulas in 11 patients (22.9%), radicular arteriovenous shunts in 7 patients (14.6%), and spinal dural arteriovenous fistulas in 30 patients (62.5%). Radicular arteriovenous shunts presented at a younger age (P = .017) and with a higher incidence of back pain symptoms (P = .037). A tethered spinal cord was found in 54.5% of patients with filum terminale arteriovenous fistulas and 23.3% of patients with spinal dural arteriovenous fistulas. After treatment, the angiographic complete obliteration rate was 89.4% and spinal function was improved significantly (P < .001). CONCLUSIONS Three groups of spinal arteriovenous shunts below the conus can be differentiated according to clinical and radiologic features. Filum terminale arteriovenous fistulas are frequently associated with dysraphic malformations, which may suggest a particular embryologic origin.
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Affiliation(s)
- T Hong
- From the Department of Neurosurgery (T.H., F.L., H.Q.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - J E Park
- Department of Radiology and Research Institute of Radiology (J.E.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - F Ling
- From the Department of Neurosurgery (T.H., F.L., H.Q.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | - M Tymianski
- Division of Neurosurgery (M.T.), Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - H Q Zhang
- From the Department of Neurosurgery (T.H., F.L., H.Q.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - T Krings
- Department of Medical Imaging (K.G.T., T.K.)
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Robaina Cabrera DM, Verde González MP, Tarazona Chocano B, Amado Fernández C, Zarrabeitia Puente R. Telangiectasia hemorrágica hereditaria: enfermedad de Rendu-Osler-Weber. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.fmc.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kawasaki T, Fukuda H, Kurosaki Y, Handa A, Chin M, Yamagata S. Acute Compressive Myelopathy Caused by Spinal Subarachnoid Hemorrhage: A Combined Effect of Asymptomatic Cervical Spondylosis. World Neurosurg 2016; 95:619.e1-619.e4. [PMID: 27567572 DOI: 10.1016/j.wneu.2016.08.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 08/07/2016] [Accepted: 08/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with subarachnoid hemorrhage (SAH) by hemorrhagic arteriovenous fistulas (AVFs) usually presents with meningeal signs, including headache and nausea, and focal neurologic deficit is found in rare cases. In this article, we report a case of acute compressive cervical myelopathy caused by hemorrhagic AVF at the craniocervical junction. CASE DESCRIPTION A 73-year-old woman was transferred to our hospital for sudden headache and subsequent left hemiparesis. Head computed tomography scan showed SAH exclusively in the posterior fossa, and catheter angiography revealed a perimedullary arteriovenous fistula at the craniocervical junction as a source of the SAH. Detailed neurologic examination showed the sensory disturbance of bilateral upper extremities and bladder and rectal disturbance, suggesting concurrent cervical myelopathy. Magnetic resonance imaging of the cervical spine showed disk herniation at the C4-5 level, spinal SAH deposition above the C4-5 level, and accompanying myelomalacia. No intramedullary hemorrhage was found. CONCLUSIONS Spinal SAH alone rarely causes focal neurologic deficit. However, this case suggests spinal SAH can cause acute compressive myelopathy when complicated with preexisting spinal canal stenosis.
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Affiliation(s)
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | | | - Akira Handa
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Okayama, Japan
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Vuong SM, Jeong WJ, Morales H, Abruzzo TA. Vascular Diseases of the Spinal Cord: Infarction, Hemorrhage, and Venous Congestive Myelopathy. Semin Ultrasound CT MR 2016; 37:466-81. [PMID: 27616317 DOI: 10.1053/j.sult.2016.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Vascular pathologies of the spinal cord are rare and often overlooked. This article presents clinical and imaging approaches to the diagnosis and management of spinal vascular conditions most commonly encountered in clinical practice. Ischemia, infarction, hemorrhage, aneurysms, and vascular malformations of the spine and spinal cord are discussed. Pathophysiologic mechanisms, clinical classification schemes, clinical presentations, imaging findings, and treatment modalities are considered. Recent advances in genetic and syndromic vascular pathologies of the spinal cord are also discussed. Clinically relevant spinal vascular anatomy is reviewed in detail.
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Affiliation(s)
- Shawn M Vuong
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - William J Jeong
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Humberto Morales
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH; Comprehensive Stroke Center, University of Cincinnati Neuroscience Institute, Cincinnati, OH
| | - Todd A Abruzzo
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH; Comprehensive Stroke Center, University of Cincinnati Neuroscience Institute, Cincinnati, OH; Department of Radiology, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH.
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27
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Cho WS, Wang KC, Phi JH, Lee JY, Chong S, Kang HS, Han MH, Kim SK. Pediatric spinal arteriovenous malformations and fistulas: a single institute's experience. Childs Nerv Syst 2016; 32:811-8. [PMID: 26872464 DOI: 10.1007/s00381-016-3035-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Pediatric spinal vascular diseases are extremely rare. We aimed to evaluate their clinical characteristics and treatment outcomes in our institute. DESIGN A total of 10 patient files were retrospectively reviewed, including 3 cases of intramedullary arteriovenous malformations (AVMs), 6 cases of perimedullary arteriovenous fistulas (AVFs), and 1 case of epidural AVF. Clinical features, radiological findings, treatment results, and clinical outcomes were evaluated. The median durations of the radiologic and clinical follow-ups were 17.7 and 107.9 months, respectively. RESULTS The male to female ratio was 1:1, with a median age at diagnosis of 9 years. All AVMs were juvenile type, all perimedullary AVFs were high flow types (three type IVb and three type IVc), and one epidural AVF was associated with intradural venous drainage. Most cases (90 %) were located in the cervical spine and conus medullaris. Acute neurological deterioration was identified in five patients; however, bleeding was identified in only one patient. Two cases were surgically treated, seven cases underwent embolization, and one case underwent radiosurgery. Three cases were completely obliterated, and their clinical states were improved (n = 2; 66.7 %) and stationary (n = 1; 33.3 %). Meanwhile, seven cases were incompletely obliterated, and their clinical states were improved (n = 2; 28.6 %), stationary (n = 3; 42.8 %), and aggravated (n = 2; 28.6 %). CONCLUSIONS Pediatric spinal AVMs and AVFs were mostly complex and high flow types, and complete obliteration could not be satisfactorily achieved. Incompletely treated lesions should be closely followed up because they may worsen.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Kyu-Chang Wang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ji Hoon Phi
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ji Yeoun Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Anatomy, Seoul National University College of Medicine, Seoul, South Korea
| | - Sangjoon Chong
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Moon Hee Han
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.,Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Seung-Ki Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea. .,Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Unsrisong K, Taphey S, Oranratanachai K. Spinal arteriovenous shunts: accuracy of shunt detection, localization, and subtype discrimination using spinal magnetic resonance angiography and manual contrast injection using a syringe. J Neurosurg Spine 2016; 24:664-70. [DOI: 10.3171/2015.7.spine15319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The object of this study was to evaluate the accuracy of fast 3D contrast-enhanced spinal MR angiography (MRA) using a manual syringe contrast injection technique for detecting and evaluating spinal arteriovenous shunts (AVSs).
METHODS
This was a retrospective study of 15 patients and 20 spinal MRA and catheter angiography studies. The accuracy of using spinal MRA to detect spinal AVS, localize shunts, and discriminate the subtype and dominant arterial feeder of the AVS were studied.
RESULTS
There were 14 pretherapeutic and 6 posttherapeutic follow-up spinal MRA and catheter spinal angiography studies. The spinal AVS was demonstrated in 17 of 20 studies. Spinal MRA demonstrated 100% sensitivity for detecting spinal AVS with no false-negative results. A 97% accuracy rate for AVS subtype discrimination and shunt level localization was achieved using this study's diagnostic criteria. The detection of the dominant arterial feeder was limited to 9 of these 17 cases (53%).
CONCLUSIONS
The fast 3D contrast-enhanced MRA technique performed using manual syringe contrast injection can detect the presence of a spinal AVS, locate the shunt level, and discriminate AVS subtype in most cases, but is limited when detecting small arterial feeders.
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Brinjikji W, Nasr DM, Cloft HJ, Iyer VN, Lanzino G. Spinal arteriovenous fistulae in patients with hereditary hemorrhagic telangiectasia: A case report and systematic review of the literature. Interv Neuroradiol 2016; 22:354-61. [PMID: 26823330 DOI: 10.1177/1591019915623560] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 11/22/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although rare, spinal arteriovenous malformations (AVMs) are thought to be more prevalent in the hereditary Hereditary Hemorrhagic Telangiectasia (HHT) population. METHODS We report a case of a spinal AVM in a 37-year-old female with HHT treated with endovascular embolization. In addition, we report findings from a systematic review of the literature on the clinical characteristics, angioarchitecture, and clinical outcomes of HHT patients with spinal AVMs. RESULTS The patient is a 37 year-old female with definite HHT who presented with a one-year history of progressive gait difficulty. The spinal fistula was incidentally detected on chest computed tomography (CT). Spinal angiography demonstrated a large perimedullary arteriovenous fistula was supplied by a posterolateral spinal artery. The fistula was treated with detachable coils. The patient made a complete neurological recovery. Our systematic review yielded 25 additional cases of spinal AVMs in HHT patients. All fistulae were perimedullary (100.0%). Treatments were described in 24 of the 26 lesions. Endovascular-only treatment was performed in 16 cases (66.6%) and surgical-only treatment was performed in five cases (20.8%). Complete or near-complete occlusion rates were 86.7% (13/15) for endovascular treated cases, 100.0% (4/4) for surgery and 66.6% (2/3) for combined treatments. Overall, 80.0% of patients (16/20) reported improvement in function following treatment, 100.0% (5/5) in the surgery group and 84.6% (11/13) reported improvement in the endovascular group. CONCLUSIONS Spinal fistulae in HHT patients are usually type IV perimedullary fistulae. Both endovascular and surgical treatments appeared to be effective in treating these lesions. However, it is clear that endovascular therapy has become the preferred treatment modality.
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Affiliation(s)
| | | | | | - Vivek N Iyer
- Department of Pulmonology and Critical Care Medicine, Mayo Clinic, USA
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30
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Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00067-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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31
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Saliou G, Krings T. Vascular diseases of the spine. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:707-16. [PMID: 27430437 DOI: 10.1016/b978-0-444-53486-6.00034-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Asada D, Itoi T, Hamaoka K. Asymptomatic spinal arteriovenous fistula presenting only as continuous murmur. Pediatr Int 2015; 57:1208-10. [PMID: 26711922 DOI: 10.1111/ped.12716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 04/13/2015] [Accepted: 05/20/2015] [Indexed: 11/28/2022]
Abstract
Spinal arteriovenous fistula is extremely rare in children. Weakness and sensory disturbance in the lower extremities are the specific clinical presentations. Children, however, commonly have no subjective symptoms; in rare cases, a continuous murmur is the only physical finding. An 18-month-old boy was referred for evaluation of a continuous murmur audible at the back. He had no motor or sensory disorder; only a Levine 3/6 continuous murmur audible at the back was found. Echocardiography showed a structurally normal heart but indicated ascending continuous blood flow behind the aortic arch and dilatation of the innominate vein. We suspected spinal arteriovenous fistula, and it was visualized on computed tomography angiography. Spinal arteriovenous fistula was detected using only auscultation and echocardiography. Suspicion of this anomaly on careful auscultation and simple examination, and confirmation on detailed examination, even in the absence of motor or sensory disturbance, is important.
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Affiliation(s)
- Dai Asada
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiyuki Itoi
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Hamaoka
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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33
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Niimi Y, Matsukawa H, Uchiyama N, Berenstein A. The Preventive Effect of Endovascular Treatment for Recurrent Hemorrhage in Patients with Spinal Cord Arteriovenous Malformations. AJNR Am J Neuroradiol 2015; 36:1763-8. [PMID: 26251426 DOI: 10.3174/ajnr.a4396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 02/04/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Spinal cord AVMs represent rare and insufficiently studied pathologic entities. Embolization is thought to play an important role in the management of spinal cord AVMs. Factors for recurrent hemorrhage and the impact of endovascular treatment on prevention of recurrent hemorrhage remain to be confirmed. We aimed to assess recurrent hemorrhagic incidence of spinal cord AVMs and its prevention by endovascular treatment. MATERIALS AND METHODS We reviewed 80 patients with spinal cord AVMs by spinal cord angiography who had hemorrhage before the first endovascular treatment at New York University Medical Center, Beth Israel Medical Center, or Roosevelt Hospital in New York. We compared the baseline and radiologic characteristics of patients with and without recurrent hemorrhage by the log-rank test and the Cox proportional hazards model. RESULTS We observed recurrent hemorrhage in 35 (44%) patients (1/41 patients with endovascular treatment and 34/39 patients without endovascular treatment). The median length of total follow-up was 659 days (interquartile range, 129-2640 days), and the median length from first-to-recurrent hemorrhage was 369 days (interquartile range, 30-1596 days). The log-rank test revealed that endovascular treatment and venous thrombosis reduced recurrent hemorrhage, and associated aneurysm was related to recurrent hemorrhage. Even in multivariate analysis, the endovascular treatment reduced (hazard ratio, 0.027; P < .0001) and associated aneurysm increased (hazard ratio, 3.4; P = .044) the risk of recurrent hemorrhage. CONCLUSIONS Endovascular embolization is the first choice of treatment for spinal cord AVMs and is effective in preventing recurrent hemorrhage.
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Affiliation(s)
- Y Niimi
- From the Departments of Neuroendovascular Therapy (Y.N.)
| | - H Matsukawa
- Neurosurgery (H.M.), St. Luke's International Hospital, Tokyo, Japan
| | - N Uchiyama
- Department of Neurosurgery (N.U.), Kanazawa University, Kanazawa, Japan
| | - A Berenstein
- Center for Endovascular Surgery (A.B.), Roosevelt Hospital, New York, New York
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34
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Batista AL, Romero DG, Gentric JC, Weill A, Raymond J, Roy D. Radiculo-pial spinal arteriovenous fistulas treated with coils: Report of two cases. Interv Neuroradiol 2015; 21:527-31. [PMID: 26111984 DOI: 10.1177/1591019915590530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Spinal pial arteriovenous fistulas (SPAVFs) are rare lesions that present more frequently in young patients. Lesions located on radiculo-pial arteries without involvement of the anterior spinal artery are even rarer. SPAVFs may present with mass effect, venous congestion or hemorrhage. Most often, treatment is performed either by surgery or endovascularly with fluid embolic material. Use of microcoils has not been reported for this condition.We present two cases of radiculo-pial high-flow SPAVFs in two patients in their early 30 s. One patient presented with abrupt headache without proof of hemorrhage and the other one with trigeminal neuralgia resulting from dilated posterior fossa draining veins remote from the fistula. Both patients were successfully treated with endovascular shunt closure using microcoils with resolution of symptoms and disappearance of the dilated veins at follow-up.With recent advances in microcatheter technology, distal navigation and microcoil embolization offers another option for these cases that may be safer than fluid embolic material.
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Affiliation(s)
- André Lima Batista
- Centre hospitalier de l'Université de Montréal (CHUM) Notre-Dame Hospital, Canada
| | | | | | - Alain Weill
- Centre hospitalier de l'Université de Montréal (CHUM) Notre-Dame Hospital, Canada
| | - Jean Raymond
- Centre hospitalier de l'Université de Montréal (CHUM) Notre-Dame Hospital, Canada
| | - Daniel Roy
- Centre hospitalier de l'Université de Montréal (CHUM) Notre-Dame Hospital, Canada
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35
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Lee YJ, Terbrugge KG, Saliou G, Krings T. Clinical Features and Outcomes of Spinal Cord Arteriovenous Malformations. Stroke 2014; 45:2606-12. [DOI: 10.1161/strokeaha.114.006087] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Young-Jun Lee
- From the Department of Medical Imaging (Y.-J.L., K.G.T., G.S., T.K.), and Division of Neurosurgery (T.K.), Toronto Western Hospital, University of Toronto, Ontario, Canada; Department of Radiology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea (Y.-J.L.); and Service de Neuroradiologie, CHU Bicêtre, Le Kremlin Bicêtre Cedex, France (G.S.)
| | - Karel G. Terbrugge
- From the Department of Medical Imaging (Y.-J.L., K.G.T., G.S., T.K.), and Division of Neurosurgery (T.K.), Toronto Western Hospital, University of Toronto, Ontario, Canada; Department of Radiology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea (Y.-J.L.); and Service de Neuroradiologie, CHU Bicêtre, Le Kremlin Bicêtre Cedex, France (G.S.)
| | - Guillaume Saliou
- From the Department of Medical Imaging (Y.-J.L., K.G.T., G.S., T.K.), and Division of Neurosurgery (T.K.), Toronto Western Hospital, University of Toronto, Ontario, Canada; Department of Radiology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea (Y.-J.L.); and Service de Neuroradiologie, CHU Bicêtre, Le Kremlin Bicêtre Cedex, France (G.S.)
| | - Timo Krings
- From the Department of Medical Imaging (Y.-J.L., K.G.T., G.S., T.K.), and Division of Neurosurgery (T.K.), Toronto Western Hospital, University of Toronto, Ontario, Canada; Department of Radiology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, Korea (Y.-J.L.); and Service de Neuroradiologie, CHU Bicêtre, Le Kremlin Bicêtre Cedex, France (G.S.)
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36
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Saliou G, Tej A, Theaudin M, Tardieu M, Ozanne A, Sachet M, Ducreux D, Deiva K. Risk factors of hematomyelia recurrence and clinical outcome in children with intradural spinal cord arteriovenous malformations. AJNR Am J Neuroradiol 2014; 35:1440-6. [PMID: 24627450 DOI: 10.3174/ajnr.a3888] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Few published data are available concerning the risk of re-bleeding of spinal cord AVM after an hematomyelia and concerning the long-term clinical outcome. Our aim was to assess the risk of recurrence and long-term clinical outcome after hematomyelia in children with spinal cord AVMs. MATERIALS AND METHODS This single-center retrospective study reviewed the clinical and radiologic data of 28 children younger than 18 years of age with arteriovenous malformation who had experienced at least 1 episode of hematomyelia between 1988 and 2012. Long-term clinical outcome was assessed by the American Spinal Injury Association Impairment Scale, and radiologic review included MR imaging and angioarchitecture on angiography (blinded to clinical information) before treatment and at recurrence. RESULTS Sixteen children (57%) experienced 1 episode of hematomyelia, while 12 children (43%) experienced recurrence. Girls and boys were equally affected (sex ratio, 1:1), and mean clinical follow-up was 5.7 ± 4.4 years. The risk of recurrence was higher for AVMs of the cervical and upper thoracic spine, 12 (100%) versus 11 (69%) (P = .01). A high American Spinal Injury Association scale score at last follow-up was reported for 11 children (39%), and the risk of recurrence tended to be associated with poorer functional prognosis (7 [64%] versus 5 [29%], P = .07). At the time of recurrence, perimedullary venous drainage was the main factor associated with recurrence (P = .002). Occlusion rate ≥50% was associated with a decreased risk of recurrence (P = .047). CONCLUSIONS In the present series, cervical and upper thoracic spinal cord AVMs and microarchitecture were predictive of the risk of hematomyelia recurrence. Perimedullary venous drainage was one of the main parameters associated with recurrence. Functional prognosis was better in patients with a single episode of hematomyelia.
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Affiliation(s)
- G Saliou
- From the Service de Neuroradiologie (G.S., M.S., D.D., A.O.)
| | - A Tej
- Service de Neurologie Pédiatrique (A.T., M. Tardieu, K.D.)
| | - M Theaudin
- Service de Neurologie (M. Theaudin), Centre Hospitalier Universitaire Bicêtre, National Referral Center for Neurovascular Malformations in Children, Le Kremlin Bicêtre Cedex, France
| | - M Tardieu
- Service de Neurologie Pédiatrique (A.T., M. Tardieu, K.D.)
| | - A Ozanne
- From the Service de Neuroradiologie (G.S., M.S., D.D., A.O.)
| | - M Sachet
- From the Service de Neuroradiologie (G.S., M.S., D.D., A.O.)
| | - D Ducreux
- From the Service de Neuroradiologie (G.S., M.S., D.D., A.O.)
| | - K Deiva
- Service de Neurologie Pédiatrique (A.T., M. Tardieu, K.D.)
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Phadke RV, Bhattacharyya A, Handique A, Jain K, Kumar A, Singh V, Baruah D, Kumar T, Patwari S, Mohan BM. Endovascular treatment in spinal perimedullary arteriovenous fistula. Interv Neuroradiol 2014; 20:357-67. [PMID: 24976100 DOI: 10.15274/inr-2014-10056] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 11/23/2013] [Indexed: 11/12/2022] Open
Abstract
This study includes 20 patients with 21 spinal perimedullary fistulae. There were nine Type IVa (42.8%) lesions, ten Type IVb (47.6%) and two Type IVc (9.5%) lesions. The dominant arterial supply was from the anterior spinal artery (47.6%), posterior spinal artery (19%) and directly from the radiculomedullary artery (28.5%). Sixteen lesions in 15 patients were treated by endovascular route using n-butyl-2-cyanoacrylate. Endovascular treatment was not feasible in five patients. Of the ten patients with microfistulae, catheterization failed/was not attempted in 40%, complete obliteration of the lesion was seen in 60% but clinical improvement was seen in 40% of patients. Catheterization was feasible in all ten patients with macrofistulae (nine type IVb and two type IVc lesions). Complete obliteration of the lesions was seen in 60% and residue in 30%. Clinical improvement was seen in 80% and clinical deterioration in 10%. In conclusion, endovascular glue embolization is safe and efficacious in type IVb and IVc spinal perimedullary fistulae and should be considered the first option of treatment. It is also feasible in many of the type IVa lesions.
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Affiliation(s)
- Rajendra V Phadke
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India -
| | | | - Akash Handique
- North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences; Shillong, Meghalaya, India
| | - Krishan Jain
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India
| | - Alok Kumar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India
| | - Vivek Singh
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India
| | - Deb Baruah
- Assam Medical College and Hospital; Dibrugarh, Assam, India
| | - Tushant Kumar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India
| | - Sriram Patwari
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India
| | - B Madan Mohan
- Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow, Uttar Pradesh, India
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39
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Abstract
Pediatric spinal arteriovenous shunts are rare and, in contrast to those in adults, are often congenital or associated with underlying genetic disorders. These are thought to be a more severe and complete phenotypic spectrum of all spinal arteriovenous shunts seen in the overall spinal shunt population. The pediatric presentation thus accounts for its association with significant morbidity and, in general, a more challenging treatment process compared with the adult presentation.
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Affiliation(s)
- Indran Davagnanam
- Lysholm Department of Neuroradiology, National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK; Brain Repair & Rehabilitation Unit, Institute of Neurology, University College London, London WC1N 3BG, UK.
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40
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Siddiq F, Adil MM, Norby KE, Rahman HA, Qureshi AI. Rates and outcomes of neurosurgical treatment for postthrombolytic intracerebral hemorrhage in patients with acute ischemic stroke. World Neurosurg 2013; 82:678-83. [PMID: 23911995 DOI: 10.1016/j.wneu.2013.07.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 07/24/2013] [Accepted: 07/25/2013] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Postthrombolytic intracerebral hemorrhage (ICH) is an infrequent occurrence in patients with acute ischemic stroke. There is controversy surrounding the value of neurosurgical treatment of symptomatic hematomas in these patients and whether availability of neurosurgical treatment is a necessary prerequisite for administration of thrombolytic agents. We report the frequency and outcomes of patients who undergo craniotomy for postthrombolytic ICH. METHODS Patients with acute ischemic stroke who experienced postthrombolytic ICH were identified using the Nationwide Inpatient Sample from 2002-2010 and International Classification of Diseases, 9th Revision, Clinical Modification codes. Patients were divided into patients who received craniotomy and patients who received medical management alone. Discharge destination and mortality were primary endpoints. RESULTS An estimated 7607 patients experienced postthrombolytic ICH; 125 (1.6%) patients underwent craniotomy, and 7482 patients (98.4%) received medical treatment alone. Patients in the craniotomy group were younger (53.7 years old ± 36 vs. 72.4 years old ± 29, P = 0.09) and were frequently in the extreme severity All Patient Refined Diagnosis Related Group category compared with patients in the medical management group (92.2% vs. 55.5%, P = 0.001). The mean length of stay was also longer in the craniotomy group (21.5 days vs. 10 days, P < 0.0001). In-hospital mortality was greater in the medical management group (30.5% vs. 24.2%, P = 0.5). After adjusting for age, gender, and All Patient Refined Diagnosis Related Group severity index, the odds ratios of in-hospital mortality, discharge to extended care facility, and discharge to home or self-care were 0.8 (95% confidence interval [CI] 0.3-2.0, P = 0.5), 5.4 (95% CI 0.6-52.0, P = 0.1), and 0.2 (95% CI 0.02-1.8, P = 0.1) for the craniotomy group compared with the medical management group. CONCLUSIONS Emergent craniotomy for postthrombolytic ICH in patients with acute stroke is a salvage treatment offered to a small proportion of patients. Although biases introduced by patient selection cannot be excluded in our analysis, the excessively high rates of death or disability associated with surgical evacuation limit the value of such a procedure in current practice.
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Affiliation(s)
- Farhan Siddiq
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Malik M Adil
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Kiersten E Norby
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Haseeb A Rahman
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, Minnesota, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
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41
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Clinical results after the multidisciplinary treatment of spinal arteriovenous fistulas. Jpn J Radiol 2013; 31:455-64. [PMID: 23722329 DOI: 10.1007/s11604-013-0216-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 05/10/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE We retrospectively evaluated the clinical outcome after multidisciplinary treatment of spinal arteriovenous fistulas (AVFs) in terms of the Aminoff-Logue grading scale (ALS) to depict the outcome in a perspective pertinent to the quality of everyday living. MATERIALS AND METHODS Twenty-six spinal AVFs in 25 patients were angiographically diagnosed from April 1998 through April 2012 and treated by endovascular embolization or surgery. When both treatment procedures seemed feasible, embolization was undertaken as the initial treatment. Motor and gait disturbance at follow-up was retrospectively graded according to ALS. RESULTS All lesions were localized at the thoracolumbar or sacral levels and include six epidural AVFs with intradural venous reflux, 14 dural AVFs, and six perimedullary AVFs. Embolization was performed as the initial treatment for 17 lesions, while open surgery was performed for the others as well as for residual or recurrent lesions after embolization. All lesions were completely occluded except three perimedullary AVFs. At clinical follow-up of 1-153 months (mean 53.3), amelioration of gait disturbance with reduction of ALS scores was noted for 13 lesions and amelioration of micturition for 13 lesions as well. CONCLUSION Clinical functional status was improved for half of the lesions after the multidisciplinary treatment.
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Qureshi AI. A new classification scheme for spinal vascular abnormalities based on angiographic features. J Neuroimaging 2012; 23:401-8. [PMID: 23227983 DOI: 10.1111/j.1552-6569.2012.00709.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND AND PURPOSE To determine the interobserver reliability of a newly proposed classification scheme for angiographic classification of spinal vascular malformations including arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs). METHOD A study was performed done in which 1-2 representative angiographic images of 26 spinal AVFs and/or AVMs were independently classified by five fellows in the ACGME accredited Endovascular Surgical Neuroradiology (ESN) program and two external interventionalists in the absence of any other clinical or imaging data. From these observations the interobserver reliability for each category and the overall scheme were determined in terms of the median weighted kappa statistic. RESULTS The overall interobserver reliability for the new classification scheme was a Kappa of 0.53 (Z = 21.3, P = <.0001) among the seven raters. The Kappa for individual grades was as follows: grade I (k = 0.66), grade II (k = 0.50), grade III (k = 0.44), and grade IV (k = 0.58). Three or more raters agreed on 100% of the cases. The interobserver reliability was high among the two practicing interventionalist raters (k = 0.55, 95% confidence interval 0.3-0.8). The interobserver reliability remained high among junior ESN fellows (k = 0.65). CONCLUSION The new classification scheme provided satisfactory reliability even in the hands of less experienced observers. The scheme can be used with minimal training and other concurrent data and can be relied upon to provide consistent results.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, Minneapolis, MN, USA.
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Sato K, Roccatagliata L, Depuydt S, Rodesch G. Multiple Aneurysms of Thoracic Spinal Cord Arteries Presenting With Spinal Infarction and Subarachnoid Hemorrhage. Neurosurgery 2012; 71:E1053-8; discussion E1058. [DOI: 10.1227/neu.0b013e3182647be4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE:
Arterial aneurysms of the spinal cord are rare. Their pathogenesis is variable, and the therapeutic strategies remain controversial, because their natural history is unclear. We report a case of multiple dissecting aneurysms of radiculomedullary and radiculopial arteries presenting with spinal infarction and subarachnoid hemorrhage, which spontaneously resolved.
CLINICAL PRESENTATION:
A 67-year-old woman was hospitalized owing to sudden onset of severe back pain with discomfort in the lower extremities. Two days later, she again experienced sudden back pain accompanied by paraparesis and sphincter disturbance. Magnetic resonance imaging of the thoracic spinal cord showed 2 intradural masses of heterogeneous intensity at the levels of T-8 and T-10, spinal infarction, and subarachnoid hemorrhage. Spinal angiography revealed a “pearls and strings” aspect of a radiculomedullary artery arising from the left T-11 and a fusiform aneurysm of a radiculopial artery arising from the left T-8. Infectious and immunological evaluations failed to show any anomaly. Spontaneous dissections were suspected. Conservative treatment was proposed, and the patient's clinical course remained uneventful. Follow-up magnetic resonance imaging and spinal angiography performed 2 months after onset showed disappearance of both arterial lesions.
CONCLUSION:
Arterial dissections of spinal radicular arteries can resolve spontaneously and be managed conservatively. We propose a classification of the pathogenesis of spinal arterial aneurysm to clarify appropriate treatment strategies by a literature review.
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Affiliation(s)
- Kenichi Sato
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Luca Roccatagliata
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
- Department of Neurosciences, Ophthalmology and Genetics, University of Genoa, Genoa, Italy
| | - Sebastien Depuydt
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
| | - Georges Rodesch
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
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Lv X, Li Y, Yang X, Jiang C, Wu Z. Endovascular embolization for symptomatic perimedullary AVF and intramedullary AVM: a series and a literature review. Neuroradiology 2012; 54:349-59. [PMID: 21556862 DOI: 10.1007/s00234-011-0880-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 04/20/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Perimedullary arteriovenous fistula (AVF) has shunt on the spinal cord surface and it can be treated with surgery, or endovascular embolization. Intramedullary arteriovenous malformation (AVM) has its nidus in the cord and is difficult to treat either by surgery or endovascular technique. We report our experience with endovascular embolization in the treatment of perimedullary AVF and intramedullary AVM. METHODS Four consecutive cases of spinal perimedullary AVF and six intramedullary AVM were retrospectively reviewed. These cases were evaluated and treated at Beijing Tiantan Hospital, China, over a 2-year period. A review of previously reported cases was also performed. RESULTS There was no significant difference in the presentations (P = 0.348), level of lesions (P = 0.350), arterial suppliers (P = 0.801), and associated vascular anomalies between perimedullary AVF and intramedullary AVM, except for age (P = 0.014) and treatment modalities (P = 0.003). The patients with perimedullary AVFs were younger in our cases; the age at onset of symptoms averaged 25.8 years compared to 31.7 years for intramedullary AVMs. There was a significant male predominance for both lesions, and a significantly higher incidence of subarachnoid hemorrhage than in spinal dural AVFs. Regarding treatment, endovascular coil embolization is frequently used in perimedullary AVF and liquid embolic agent is an effective therapeutic choice in intramedullary AVM. CONCLUSION Perimedullary AVF and intramedullary AVM are dissimilar with dural AVF in clinical characteristics. Our experience suggests that the endovascular treatment of spine perimedullary AVFs and intramedullary AVMs is feasible and effective. Endovascular treatment for intramedullary AVMs is still challenging, the main problem is acute ischemia injury of the spinal cord.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Chongwen, Beijing 100050, People's Republic of China
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Angiogenic and inflammatory factor expressions in cutaneomeningospinal angiomatosis (Cobb's syndrome): case report. Acta Neurochir (Wien) 2011; 153:1657-61. [PMID: 21519966 DOI: 10.1007/s00701-011-1025-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 04/06/2011] [Indexed: 10/18/2022]
Abstract
We report on a case of cervical cutaneomeningospinal angiomatosis (Cobb's syndrome), a rare somatic disorder, characterized by vascular abnormalities of the spinal cord, with a triad of associated vascular skin, muscle, bone, and dura involvement at the same somite. This case follows an 18-year-old male patient presenting with left extremity weakness and back cervical pain. Magnetic resonance imaging (MRI) revealed a spinal cord arteriovenous malformation (AVM) at the C3-C5 level. Cobb's syndrome was diagnosed by coexistence of cutaneous naevi in a dermatomal pattern and neurological signs of a spinal cord lesion together with cervical MRI and angiography. The patient underwent a combination of staged endovascular embolization and microsurgical resection. Multiple biopsies of the mass including the skin, muscle, dura, and spinal cord at the same somite revealed that the lesions had a similar pathology. Post-operative immunohistochemical characterizations on specimen included CD31, smooth muscle actin (SMA), vascular endothelial growth factor (VEGF), and matrix metalloproteinase (MMP-9). The unique associations of somatic and spinal cord lesion as well as angiogenic and inflammatory factor expressions in all specimens are reported.
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Casasco A, Guimaraens L, Senturk C, Cotroneo E, Gigli R, Theron J. Endovascular Treatment of Cervical Giant Perimedullary Arteriovenous Fistulas. Neurosurgery 2011; 70:141-9; discussion 149. [DOI: 10.1227/neu.0b013e31822ec19e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Giant perimedullary arteriovenous fistulas (GPMAVFs) located in the cervical region are a rare pathology with distinctive characteristics.
OBJECTIVE
To evaluate clinical presentation and different endovascular treatment options of cervical GPMAVFs and review previously published data in the literature regarding cervical GPMAVFs.
METHODS
Six patients with cervical GPMAVFs were found in the spinal vascular malformations database of our group collected between 1990 and 2009. Endovascular techniques and treatment outcomes were evaluated and compared with other published series.
RESULTS
Clinical presentations were progressive motor deficit (5 patients), hematomyelia (1 patient), meningeal syndrome (1 patient), and respiratory arrest and gait apraxia (1 patient). Three patients were treated by the transarterial approach. One patient was treated by the transvenous approach due to previous embolizations resulting in a proximal occlusion and preventing a safe transarterial approach. A transvenous approach was used in another patient due to complex arterial anatomy. In 1 patient, direct percutaneous puncture of the venous pouch was necessary because of previous proximal occlusion of the arteries. All embolizations resulted in complete occlusions with clinical improvement, and there was no recanalization during a mean follow-up of 21 months.
CONCLUSION
Transarterial embolization of cervical GPMAVFs is safe and effective when it is done in highly experienced centers. Cervical GPMAVFs that cannot be accessed by the transarterial technique due to their complex angioarchitecture can be treated by transvenous embolization or direct puncture of the venous pouch.
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Affiliation(s)
- Alfredo Casasco
- Department of Endovascular and Percutaneous Therapy, Hospital Nuestra Señora del Rosario, Madrid, Spain
| | - Leopoldo Guimaraens
- Department of Endovascular and Percutaneous Therapy, Hospital Nuestra Señora del Rosario, Madrid, Spain
- Department of Therapeutic Neuroangiography, Hospital General de Cataluña, Barcelona, Spain
| | - Cagin Senturk
- Department of Endovascular and Percutaneous Therapy, Hospital Nuestra Señora del Rosario, Madrid, Spain
- Department of Radiological Sciences, Division of Neurointerventional Radiology, University of California Irvine Medical Center, Orange, California
| | - Enrico Cotroneo
- Department of Neuroradiology, Hospital San Camilo, Roma, Italy
| | - Renato Gigli
- Department of Neuroradiology, Hospital San Camilo, Roma, Italy
| | - Jacques Theron
- Department of Endovascular and Percutaneous Therapy, Hospital Nuestra Señora del Rosario, Madrid, Spain
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Krings T, Geibprasert S, Karel ter Brugge. Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pediatric high-flow, cervical spinal, macro-arteriovenous fistula, treated with the endovascular cotton candy glue injection technique. Childs Nerv Syst 2010; 26:1633-8. [PMID: 20521056 DOI: 10.1007/s00381-010-1181-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 05/10/2010] [Indexed: 10/19/2022]
Abstract
A 3-year-old boy presented to our hospital with progressive neurological deficits. Spinal magnetic resonance imaging (MRI) revealed a perimedullary macro-arteriovenous fistula (PMAVF) resulting in a large venous pouch within the parenchyma of the lower cervical spinal cord. Transarterial varix embolization of the fistula from the venous side was performed using N-butyl cyanoacrylate with tantalum powder. Postembolization angiography confirmed obliteration of the fistula, and MRI revealed thrombosis and reduction in size of the venous component. The patient's clinical symptoms were reduced dramatically following the intervention, and no neurological complications occurred due to the treatment. The prognosis of spinal PMAVF depends primarily on the presence of medullar signs and symptoms and on time to treatment. The volume of the venous pouch after the intervention was markedly reduced, and complete clinical recovery was obtained. Urgent endovascular intervention, as seen in this case, is considered first-line therapy and aims to decrease the risk of neurological sequela.
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Patsalides A, Knopman J, Santillan A, Tsiouris AJ, Riina H, Gobin YP. Endovascular treatment of spinal arteriovenous lesions: beyond the dural fistula. AJNR Am J Neuroradiol 2010; 32:798-808. [PMID: 20651018 DOI: 10.3174/ajnr.a2190] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
During the past few decades, there have been significant advances in the understanding of spinal vascular lesions, mainly because of the evolution of imaging technology and selective spinal angiography techniques. In this article, we discuss the classification, pathophysiology, and clinical manifestations of spinal vascular lesions other than DAVFs and provide a review of the endovascular approach to treat these lesions.
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Affiliation(s)
- A Patsalides
- Division of Interventional Neuroradiology, Departments of Radiology and Neurosurgery, New York Presbyterian Hospital/Weill Cornell Medical College, NY 10065, USA.
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Meng X, Zhang H, Wang Y, Ye M, He C, Du J, Ling F. Perimedullary arteriovenous fistulas in pediatric patients: clinical, angiographical, and therapeutic experiences in a series of 19 cases. Childs Nerv Syst 2010; 26:889-96. [PMID: 20107995 DOI: 10.1007/s00381-009-1071-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2009] [Accepted: 12/09/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to review our pediatric series of perimedullary arteriovenous fistula (PMAVF), investigating the clinical characteristics, angioarchitecture, treatment strategy, and outcome of PMAVF in pediatric patients. METHODS AND MATERIALS Nineteen children with PMAVF treated in Xuanwu Hospital between 1986 and 2007 were reviewed. The demographic data, clinical symptoms, angiographical characteristics, classification, treatment modality, and outcome were compiled and analyzed. Clinical status was evaluated according to the modified Aminoff and Logue scale. RESULTS In our pediatric series of PMAVF, the mean age of diagnosis was 8.1 years (range, 0.8-13.7 years). Male predominance was found in our series (M/F ratio, 3.75:1). Eleven children (57.9%) presented with acute onset of symptoms, and eight cases (42.1%) had progressive evolution of the diseases. In 13 cases (68.4%), the fistulas were classified as type III, with type II in six cases. Four lesions (21.1%) were located in the cervical region, with 15 lesions (78.9%) in thoracolumbar region. Ten cases (II = 2, III = 8) were treated with embolization, and nine (II = 4, III = 5) with combined embolization and complementary surgery. According to the criteria of therapeutic effectiveness, 31.6% of cases (6/19) were cured, and nine patients (47.4%) had improved. CONCLUSIONS PMAVFs in pediatric population exhibit many characteristics in clinical and angiographical aspects, need for special considerations. Most of PMAVFs in pediatric patients are high-flow fistulas, and endovascular embolization should be the first choice of treatment. After appropriate therapy, most of children can get satisfactory outcomes.
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Affiliation(s)
- Xiaoli Meng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Xuanwu District, Beijing, People's Republic of China
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