Spinal arteriovenous malformations

Clipping and exclusion of a thoracic pial arteriovenous fistula with multiple shunting points: how I do it

BACKGROUND

Thoracic pial arteriovenous fistulas (pAVFs) are rare vascular malformations that usually consist of a single dilated pial artery connecting directly to an enlarged draining vein. Multiple shunting point thoracic pAVFs are even rarer entities causing progressive myelopathy.

METHOD

We present our surgical technique to identify and exclude multiple shunting point thoracic pAVF with appropriate pre-operative planning. This surgical technique is illustrated by an intraoperative video.

CONCLUSION

Double injection pre-operative angiography represents a helpful tool to plan the surgery. Intraoperative exposure with pedicle removal and the use of micro-Doppler improve the identification and the exclusion of a multiple shunting thoracic pAVF.

Conus medullary arteriovenous malformation mimicking intramedullary tumor: a case report

Background

Vascular malformation of the spine accounted for 3–4% of all intradural lesions. Spinal arteriovenous malformation (AVM) is often missed because of overlapping symptoms with other pathology and ambiguous imaging. Here, we report a conus medullary AVM that mimics intramedullary tumours either from clinical findings or MR imaging.

Case presentation

We report a 24-year-old man with left foot monoparesis, paresthesia, and intermittent claudication for the last 3 months. Magnetic resonance imaging revealed a strongly enhanced intramedullary lesion with a hypointense signal on T1-weighted images and a hyperintense signal on T2-weighted images without flow void, suggesting an intramedullary tumour of ependymoma. Left-sided hemilaminectomy was performed, revealing an AVM on conus medullary. Microsurgical resection was performed by subsequently ligating the arterial feeder and draining vein using a temporary clip. Improvement of neurological status without postoperative sequelae was noted.

Conclusions

Because of the similarity in epidemiology, symptoms, clinical progression, and imaging, suspicion of spinal AVM should remain. This case highlights that appropriate and meticulous surgical resection can preserve the patient's neurological function.

Spinal Vascular Shunts: Single-Center Series and Review of the Literature of Their Classification

Spinal arteriovenous shunts (sAVSs) are an uncommon disease, constituting 3 to 4% of intradural lesions; 70% of these lesions are spinal arteriovenous fistulas (sAVFs), whereas spinal arteriovenous malformations (sAVMs) are rarer. Both share the problem of their classification due to the heterogeneity of their angioarchitecture. The aim of this study is to report a series of sAVSs treated in the neurosurgery department of the Hospital Nacional Guillermo Almenara during the 2018–2020 period and to present an overview of the current literature on sAVS classification. We reviewed all medical records of patients diagnosed with sAVFs and sAVMs during the 2018–2020 period, and then we analyzed images with Horos v4.0.0, illustrated some cases with Clip Studio Paint v1.10.5, and performed a descriptive statistical analysis with SPSS v25. Twelve patients were included in this study, eight of which were women (67%) and four of which were men (33%); the age range was from 3 to 74 years. Eight sAVSs were sAVFs, whereas four were sAVMs. The most frequent clinical manifestation was chronic myelopathy in seven patients (58%). Of those treated only by embolization, seven (70%) resulted in complete occlusion (five sAVFs and two sAVMs), while three (30%) remained with a residual lesion. At last follow-up, five patients (42%) improved clinically, and the seven remaining (58%) maintained the same neurological state. sAVSs require a detailed study of their angioarchitecture for proper management. The endovascular treatment is safe with acceptable cure rates. The surgical option should not be set aside.

Spinal Arteriovenous Malformation: Case Report and Review of the Literature

Spinal arteriovenous malformations (AVMs) are a rare form of spinal blood vessel defect that results in vessel engorgement leading to clinical signs secondary to mass effect and ischemia. We present the patient’s clinical course following suspicion of spinal AVM along with a review of current classification and imaging modalities.

Natural history and management of spinal cord arteriovenous shunts in pregnancy: A monocentric series of 10 consecutive cases with emphasis on endovascular treatment

PURPOSE

Intradural spinal cord arteriovenous shunts (IDSCAVS) are rare and constitute a challenging situation if symptoms occur during pregnancy. We present a series of ten such cases referred to our center: five cervical, four thoracic and one lumbar.

METHODS

We retrospectively reviewed our global series of 215 IDSCAVSs between 2002 and March 2020 and found ten patients who had presented during pregnancy. Clinical, radiological and therapeutic data were studied.

RESULTS

Seven shunts were AVM type niduses and three were micro AV-fistulae. All were associated with pial venous reflux and six hemorrhagic cases had pseudo aneurysms. Symptoms occurred mainly during the third trimester, 80% of patients presented with hemorrhage and spinal cord dysfunction. We embolized seven patients and proposed surgery in one, always after delivery: all recovered well. One woman declined treatment; one other was operated in emergency but did not improve. Mean follow-up was 3.9 years (0.5-19 years).

CONCLUSIONS

Despite this small group of patients, our initial experience of IDSCAVSs diagnosed during pregnancy indicates that embolization is an effective management strategy if performed after delivery and a recovery period. Results indicate that IDSCAVSs seem to have a low risk of early rebleedings after the ictal event and may be closely followed up until delivery. The results obtained show good clinical outcome without long-term rebleeds. Women with known IDSCAVSs should not be discouraged from becoming pregnant, however it seems wise to embolize them before pregnancy in order to offer protection against risks during pregnancy.