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Khan UA, Koumellis P, Almahfoudh R, Foroughi M. Bilateral mirror image lumbar spinal dural arterial venous fistula: a rare case and systematic review of the literature. Br J Neurosurg 2023; 37:982-985. [PMID: 33904360 DOI: 10.1080/02688697.2021.1914822] [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: 02/08/2020] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Spinal dural arteriovenous fistulas (SDAVF) are rare with an incidence of 5-10/million annually. They can be difficult to diagnose causing a delay in treatment with significant morbidity. We describe the first case in the literature of a symptomatic mirror lumbar SDAVF which may go unnoticed due to its unique vascular anatomy. CASE DESCRIPTION A 78-year-old gentleman presented with a progressive deterioration in his walking distance and urinary retention. An initial MRI scan of the whole spine did not show features suggestive of an underlying vascular malformation. During further investigations of neurological causes, the patient continued to have progressive symptoms over a 10-month period resulting in a repeat MRI scan. This showed a new finding of cord oedema without abnormal flow voids. He went on to have vascular imaging which demonstrated a mirror L3 SDAVF and underwent subsequent surgical management. At follow up there was a significant improvement in symptoms. CONCLUSIONS Completing a systematic review of the literature we find that the mirror lumbar SDAVF in our patient presented in a more aggressive manner with symptoms progressing faster than in single or multi-level SDAVF. Our case demonstrates how this unique vascular anatomy may result in a diagnostic challenge, behaving in an occult way where typical findings are not seen on initial MRI scanning. We provide an argument for early vascular imaging which can result in the treatment of these lesions in a timely manner.
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Affiliation(s)
| | | | - Rafid Almahfoudh
- Department of Neurosurgery, Royal Sussex County Hospital, Brighton, UK
| | - Mansoor Foroughi
- Department of Neurosurgery, Royal Sussex County Hospital, Brighton, UK
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Mochizuki T, Ryu B, Sato S, Kawamata T, Niimi Y. De Novo Radicular Arteriovenous Fistula After Treatment of Spinal Arteriovenous Fistula: A Case Report and Literature Review. Cureus 2023; 15:e43348. [PMID: 37700934 PMCID: PMC10493201 DOI: 10.7759/cureus.43348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
De novo spinal dural arteriovenous fistulas (AVFs) have been reported as metachronous AVFs However, metachronous spinal AVFs are extremely rare, and their pathogenesis remains uncertain. We report a case of de novo radicular AVF (RAVF) following treatment for spinal AVF at the craniocervical junction (CCJ). We also reviewed the literature and discussed the pathogenesis of metachronous spinal AVF. A 64-year-old male patient diagnosed with spinal AVF at the CCJ supplied from the right C1 segmental artery was treated with Onyx-18 (eV3 Inc, CA, USA) trans-arterial embolization, resulting in partial occlusion. Angiography showed a slight residual shunt two weeks after the embolization without another shunt lesion. A five-year follow-up spinal angiography showed de novo RAVF at the C4 level and complete occlusion of the first AVF. The second AVF was not treated because it was asymptomatic, and the patient remained asymptomatic. De novo RAVF was found to develop five years after the embolization of a CCJ-spinal AVF in a patient. This is the first case of de novo RAVF post-treatment of a spinal AVF. This case demonstrated that RAVF could develop as an acquired disease.
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Affiliation(s)
- Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, JPN
| | - Bikei Ryu
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, JPN
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, JPN
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, JPN
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, JPN
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Song Z, Ma Y, Hong T, Zhang H. Arteriovenous Fistulas Fed by Spinal Arterial Feeders at the Craniocervical Junction Region. Oper Neurosurg (Hagerstown) 2022; 23:472-481. [DOI: 10.1227/ons.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/14/2022] [Indexed: 11/06/2022] Open
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Metachronous spinal dural arteriovenous fistula: Case report and review of literature on implications for pathophysiology and management. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Hedjoudje A, Peng X, Gautam A, Pardo CA, Sciubba D, Gailloud P. Case of Cowden Syndrome with 15 Spinal Arteriovenous Fistulas. World Neurosurg 2020; 139:567-576. [PMID: 32344142 DOI: 10.1016/j.wneu.2020.04.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spinal vascular malformations are rarely multiple: fewer than 50 observations have been documented so far, with a maximum of 4 coexisting lesions per patient, always restricted to a single vertebral region (e.g., cervical or thoracic). CASE DESCRIPTION We describe the case of a 61-year-old woman with Cowden syndrome with 15 spinal arteriovenous fistulas (AVFs) at the cervical, thoracic, and lumbar levels and an adrenal AVF. She was initially referred for reevaluation of an upper cervical spinal epidural spinal arteriovenous fistula diagnosed 6 years earlier. Her history included breast carcinoma, a malignant salivary gland tumor, and removal of multiple ovarian, thyroid, and gastric hamartomas. Computed tomography and magnetic resonance imaging confirmed the presence of a prominent cervical vascular lesion. Spinal digital subtraction angiography revealed the presence of 15 additional vascular anomalies. CONCLUSIONS This multiplicity of AVFs appears to result from a combination of various factors including local regional hemodynamic changes, growth factor-mediated alterations involving notably vascular endothelial growth factor pathways, and the prothrombotic state associated with abnormalities in blood vessel structure.
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Affiliation(s)
- Abderrahmane Hedjoudje
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
| | - Xiao Peng
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ayushi Gautam
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Sciubba
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Ren Y, Liu H, Chen TY, Li J. True metachronous multiple spinal dural arteriovenous fistulas: case report and review of the literature. Br J Neurosurg 2019:1-5. [PMID: 31204526 DOI: 10.1080/02688697.2019.1630556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Spinal dural arteriovenous fistulas (DAVFs) are the most common type of spinal vascular disorders. Multiple spinal DAVFs are very rare, and the majority of them appear synchronously. True metachronous multiple spinal DAVFs occur even more rarely. We report a case of true metachronous multiple spinal DAVFs. A 61-year-old male presented with progressive paraparesis. Spinal MRI showed extensive edema of the spinal cord from T5 to the conus and prominent vascular flow voids. MR angiography showed a left T10 DAVF. The fistula was treated surgically and the clinical symptoms gradually resolved. Recurrence of symptoms occurred 4 months after surgery. A second angiography showed a new fistula located at the right L1. The second fistula was treated surgically and the symptoms again gradually improved. Metachronous multiple spinal DAVF may present within 4 months of each other.
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Affiliation(s)
- Yanming Ren
- a Department of Neurosurgery , West China Hospital of Sichuan University, Chengdu , Sichuan , PR China
| | - Hao Liu
- a Department of Neurosurgery , West China Hospital of Sichuan University, Chengdu , Sichuan , PR China
| | - Teng-Yun Chen
- a Department of Neurosurgery , West China Hospital of Sichuan University, Chengdu , Sichuan , PR China
| | - Jin Li
- a Department of Neurosurgery , West China Hospital of Sichuan University, Chengdu , Sichuan , PR China
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Xing XZ, Guan BL, Jie LX. Directional multistage intraoperative microvascular Doppler in the hemilaminectomy surgical obliteration of spinal dural arteriovenous fistular. Clin Neurol Neurosurg 2019; 176:61-66. [DOI: 10.1016/j.clineuro.2018.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/04/2018] [Accepted: 11/18/2018] [Indexed: 11/25/2022]
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Jablawi F, Mull M. Double spinal dural arteriovenous fistulas. J Neuroradiol 2018; 46:168-172. [PMID: 30389511 DOI: 10.1016/j.neurad.2018.09.004] [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: 11/05/2017] [Revised: 07/04/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Spinal dural arteriovenous fistulas (SDAVF) are usually solitary lesions. Synchronous and/or metachronous double SDAVF have rarely been reported in the literature. We report on three patients with double SDAVF and present our single center experience in the diagnostic and treatment management in these patients. MATERIAL AND METHODS We retrospectively revised our medical database for all patients who were diagnosed and treated in our center due to a SDAVF between 1990 and 2017. All data including demographics, clinical presentations, as well as radiological data were re-evaluated for this study. RESULTS Three (1.4%) of 209 consecutive patients with SDAVF presented double SDAVF with different arterial feeders and venous drainage patterns. All three patients were men. The mean age at time of diagnosis was 67.9 ± 10 years (median; 68, range: 53-82). Myelopathic symptoms were reported in all three cases. All three fistulas were located in the thoracolumbar region between T7 and L2. MRI/CE-MRA showed medullar T2-hyperintensity, intramedullary contrast-enhancement and dilatation of perimedullary veins in various extensions. CONCLUSION Double SDAVF are extremely rare and were found in 1.4% of patients in our series. The vast majority of the reported double SDAVF in the literature has been detected synchronously within an area of equal or less than three vertebral levels. Thus, whenever the SDAVF is identified, further injections of the fistula-zone neighbored segmental arteries might be recommended. However, due to the extremely low incidence of double SDAVF a complete spinal DSA is not indicated.
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Affiliation(s)
- F Jablawi
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Pauwelsstrasse, 30, 52074 Aachen, Germany; Department of Neurosurgery, Justus-Liebig-University, Klinikstrasse, 33, 35392 Giessen, Germany
| | - M Mull
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Pauwelsstrasse, 30, 52074 Aachen, Germany.
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Spinal arteriovenous fistulas in adults: management of a series of patients treated at a Neurology department. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2016.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Rosi A, Consoli A, Condette-Auliac S, Coskun O, Di Maria F, Rodesch G. Concomitant conus medullaris arteriovenous shunts and sacral dural arteriovenous fistulas: pathophysiological links related to the venous drainage of the lesions in a series of five cases. J Neurointerv Surg 2018; 10:586-592. [DOI: 10.1136/neurintsurg-2017-013505] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 11/03/2022]
Abstract
BackgroundSpinal cord arteriovenous shunts (scAVSs) are a group of lesions located in the spinal cord itself or in the surrounding structures. The most common scAVSs are spinal dural arteriovenous fistulas (sDAVFs), which are acquired lesions. The pathogenesis of sDAVFs involves thrombosis and venous hypertension as trigger factors. Intradural scAVSs such as spinal cord arteriovenous nidus type malformations (AVMs) and pial arteriovenous fistulas are less common than sDAVFs and are considered to have a so-called ‘congenital’ origin. The association between different concomitant scAVSs is very rare and the association of sDAVFs with intradural scAVSs has been described in only a few case reports.MethodsWe describe a case series of five patients presenting with a conus medullaris AVS associated with a lower lumbar or sacral DAVF.ResultsThree of our patients were <30 years old at presentation. In four of these five cases the intradural scAVS drained caudally, engorging the epidural plexus in the same location as the sDAVF. In only one case, who presented with thrombosis of the drainage of the main compartment of a conus medullaris pial AVF, was the location of the DAVF opposite to the location of the residual drainage.ConclusionWe discuss the pathophysiological link between scAVS and sDAVF on the basis of the rarity of the DAVF, the uncommon association between scAVS and sDAVF, the presence of sDAVF in young patients, and the venous hypertension created by the venous drainage towards the sacral area responsible for angiogenesis creating the dural shunt.
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Remote Lesions of Synchronous Sacral and Cervical Dural Arteriovenous Fistulas: A Case Report. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ortega-Suero G, Porta Etessam J, Moreu Gamazo M, Rodríguez-Boto G. Spinal arteriovenous fistulas in adults: Management of a series of patients treated at a neurology department. Neurologia 2017; 33:438-448. [PMID: 28215907 DOI: 10.1016/j.nrl.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/29/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Spinal arteriovenous fístulas (SAVF), a rare type of vascular malformation, account for 3% of all spinal cord lesions. Without early treatment, the associated morbidity is high; furthermore, SAVF pose a major diagnostic challenge. Our purpose was to evaluate the clinical characteristics of SAVF and review their progress after treatment to determine whether it may be too late for treatment in some cases. METHODS We present a retrospective series of 10 patients diagnosed with SAVF and treated at a tertiary hospital during a 3-year period. RESULTS In our sample, SAVF were found to be significantly more frequent in men (80%). Mean age in our sample was 65.4 years. The most common initial symptom was intermittent claudication/paraparesis (70%). In most patients, symptoms appeared slowly and progressively. At the time of diagnosis, the most common symptoms were motor, sensory, and sphincter disorders. Mean time from symptom onset to diagnosis was 24.3 months. Initial diagnosis was erroneous in 60% of the patients. Spinal MRI was diagnostic in 90% of these cases and arteriography in 100%. The most common location of the fistula was the lower thoracic region and the most frequent type was dural (7 cases). All patients were treated with embolisation, surgery, or both and 70% improved after fistula closure regardless of progression time. CONCLUSIONS Diagnosis of SAVF is difficult and often delayed, which leads to poorer patient prognosis. We should have a high level of suspicion for SAVF in patients with intermittent claudication or paraparesis exacerbated by exercise. Early treatment should be started in these patients. Treatment should always aim to improve quality of life or stabilise symptoms, regardless of progression time.
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Affiliation(s)
- G Ortega-Suero
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España.
| | - J Porta Etessam
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
| | - M Moreu Gamazo
- Unidad de Neurorradiología Intervencionista, Servicio de Radiología, Hospital Clínico San Carlos, Madrid, España
| | - G Rodríguez-Boto
- Servicio de Neurocirugía, Hospital Clínico San Carlos, Madrid, España
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