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Ge Y, Lai Q, Guo W, Xu X. Risk factors for postoperative late deterioration in patients with spinal dural arteriovenous fistulas. Front Neurol 2024; 15:1412237. [PMID: 39040537 PMCID: PMC11260714 DOI: 10.3389/fneur.2024.1412237] [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] [Received: 04/08/2024] [Accepted: 06/20/2024] [Indexed: 07/24/2024] Open
Abstract
Background Approximately 86% of patients with spinal dural arteriovenous fistulas (SDVAFs) exhibit clinical improvement after surgery. However, 12%-55.8% of these patients experience late deterioration (LD) after an initial period of improvement. The risk factors for LD remain unclear. The aim of this study was to explore the risk factors for LD in SDVAF patients. Methods The clinical data of patients who were admitted to two tertiary hospitals between June 2014 and May 2022 were reviewed. Patients were divided into two groups: the LD group and the no LD group. The severity of neurological dysfunction (NDF) was evaluated using the Modified Aminoff and Logue Scale. Univariable and multivariable Cox regression analyses were performed. Results A total of 105 eligible patients were enrolled, with a mean age of 57.55 ± 9.42 years. The LD group comprised 37 individuals, while the no LD group consisted of 68 individuals. According to the univariable analysis, preoperative NDF severity and treatment strategy were associated with the risk of LD. According to the multivariable analysis, patients who underwent microsurgery (MS) had a lower risk of LD than did those who underwent endovascular treatment (EVT; HR 0.197, 95% CI 0.085-0.457), and patients with severe NDF had a higher risk of LD than did those with mild NDF (HR 3.604, 95% CI 1.226-10.588), whereas the risk of LD in patients with moderate NDF was similar to that of patients with mild NDF (HR 1.352, 95% CI 0.519-3.524). Conclusion EVT and severe preoperative NDF are independent risk factors for LD.
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Affiliation(s)
- Yuanhong Ge
- Department of Neurosurgery, Chengdu Second People’s Hospital, Chengdu, China
| | - Qingjia Lai
- Department of Rehabilitation, Care Alliance Rehabilitation Hospital of Chengdu, Chengdu, China
| | - Wei Guo
- Department of Neurosurgery, Tangdu Hospital, Air Force Military Medical University, Xi’an, China
| | - Xuejun Xu
- Department of Neurosurgery, Chengdu Second People’s Hospital, Chengdu, China
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Ryu B, Mochizuki T, Shima S, Sato S, Inoue T, Kawamata T, Niimi Y. Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain. Clin Neuroradiol 2024:10.1007/s00062-024-01403-5. [PMID: 38592446 DOI: 10.1007/s00062-024-01403-5] [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: 01/09/2024] [Accepted: 03/01/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND AND PURPOSE The prognosis of untreated spinal arteriovenous malformations (SAVMs) is poor. Embolization plays an important role in the management of intramedullary SAVMs. Delayed aggravation due to spinal venous thrombosis following successful embolization has been reported; however, perioperative management strategies to prevent thrombosis have not been explored. We present our single-center experience of SAVM embolization and perioperative management, including anticoagulation. MATERIAL AND METHODS We retrospectively evaluated 18 patients with SAVMs who underwent transarterial embolization. Perioperative anticoagulation therapy was administered to selected patients. We compared the characteristics of the patients, including perioperative management procedures, between those with and without postoperative worsening following embolization. RESULTS Acute postoperative worsening within 1 week occurred in 4 (22.2%) patients. Of these, immediate worsening was observed in one patient as a procedure-related complication. Delayed worsening after 24 h was observed in 3 patients, caused by delayed venous thrombosis with severe back pain. Rescue anticoagulation for delayed worsening improved symptoms in two patients. A comparison between patients with and without acute postoperative worsening revealed significant differences in age (median 46.5 vs. 26.5 years, p = 0.009) and the presence of postoperative back pain (75.0% vs. 0%, p = 0.005); however, there was no significant difference in use of selective anticoagulation (p = 0.274). CONCLUSION The results of this study suggest that SAVM embolization can cause acute worsening due to postoperative venous thrombosis with severe back pain, which may be reversed by anticoagulation therapy. Back pain is an important finding that suggests venous thrombosis, and anticoagulation should be urgently administered.
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Affiliation(s)
- Bikei Ryu
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan.
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan.
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan.
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
| | - Shogo Shima
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan
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Miyahara T, Hattori G, Uchikado H, Kaku Y, Ohmori Y, Orito K, Takeuchi Y, Kawano T, Hirohata M, Mukasa A, Morioka M. Factors Associated with Rapidly Deteriorating Myelopathy in Patients with Spinal Arteriovenous Shunts. Neurol Med Chir (Tokyo) 2021; 62:65-74. [PMID: 34776462 PMCID: PMC8841232 DOI: 10.2176/nmc.oa.2020-0439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Spinal arteriovenous (AV) shunts are rare conditions that sometimes present with myelopathy symptoms. The progression of the symptoms is usually gradual; however, some cases show rapid deterioration. We retrospectively investigated the factors that induced the rapid deterioration of myelopathy symptoms in patients with spinal AV shunts. We treated 33 patients with myelopathy with spinal AV shunts at our institutions, eight of whom experienced rapid deterioration (within 24 hours: 24.2%). Of these, three were related to the body movement or particular postures associated with playing golf, 30 minutes of Japanese straight sitting, and massage care. One patient showed deterioration after embolization for a tracheal aneurysm. The remaining four patients received steroid pulse therapy (high-dose steroid infusion) shortly before the rapid deterioration. These symptoms stopped progressing after cessation of steroid use. While positional or physical factors contributing to myelopathy deterioration might exist, we could not identify specific factors in this study. Nevertheless, rapid deterioration was frequently observed after high-dose steroid use. We must take care not to administer high-dose steroids for myelopathy caused by spinal AV shunt disease.
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Affiliation(s)
- Takahiro Miyahara
- Department of Neurosurgery, Kurume University School of Medicine.,Yame General Hospital
| | - Gohsuke Hattori
- Department of Neurosurgery, Kurume University School of Medicine
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine.,Uchikado Neurospine Clinic
| | - Yasuyuki Kaku
- Department of Neurosurgery, Kumamoto University School of Medicine
| | - Yuki Ohmori
- Department of Neurosurgery, Kumamoto University School of Medicine
| | - Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine
| | | | - Takayuki Kawano
- Department of Neurosurgery, Kurume University School of Medicine.,Department of Neurosurgery, Kumamoto University School of Medicine
| | - Masaru Hirohata
- Department of Neurosurgery, Kurume University School of Medicine
| | - Akitake Mukasa
- Department of Neurosurgery, Kumamoto University School of Medicine
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine
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Acute and subacute myelopathy. Rev Neurol (Paris) 2020; 177:557-566. [PMID: 34024334 DOI: 10.1016/j.neurol.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 11/21/2022]
Abstract
Myelopathy is a term referring to any pathologic process affecting the spinal cord, and encompasses a broad spectrum of etiologies. The first step is to categorize myelopathy, according to the time to reach maximum deficit. Myelopathies are commonly classified as acute, subacute or chronic, for which the etiologies are totally different. Myelopathy is considered acute when the symptoms progress to their nadir in maximum 21 days after onset. Due to heterogeneity in pathogenesis, and the overlap in the clinical and imaging presentation among etiologies, acute myelopathy is considered as a diagnostic dilemma. A simple and efficient algorithm for timely identification of the underlying cause is thus useful. In this review, we provide a simplified approach for the differential diagnosis among all causes of acute myelopathies, and describe the principal clinical and imaging features of the main etiologies in adults, including recently characterized antibody-mediated myelitis, and its mimics.
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Wojciechowski J, Kunert P, Nowak A, Dziedzic T, Czernicki T, Wójtowicz K, Leśniewski K, Marchel A. Surgical treatment for spinal dural arteriovenous fistulas: Outcome, complications and prognostic factors. Neurol Neurochir Pol 2017; 51:446-453. [PMID: 28826919 DOI: 10.1016/j.pjnns.2017.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/31/2017] [Accepted: 07/03/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND PURPOSE Spinal dural arteriovenous fistulas (SDAVFs) are rare, acquired pathology and they inevitably lead to severe disability if untreated. The aim of this study is to present the outcome and complications, and to find factors that may affect the outcome after surgical treatment. METHODS Seventeen consecutive patients (men - 14, women - 3, age: 41-79) were retrospectively analyzed. The patients presented with paraparesis (88%), bladder symptoms (71%) and/or sensory disturbances (65%). The fistula was found in the upper thoracic spine in 2 cases, in the lower thoracic (T7-Th12) in 11 cases, and in the lumbar spine in 4 cases. Microsurgical shunt interruption was performed in all, followed by epidural arteries coagulation in 12 cases. RESULTS In the long term, improvement or achievement of a good stable condition was observed in 13 patients (76%), and no patient deteriorated. All 5 paraplegic patients improved by at least 1 grade in MCS. Satisfactory results (modified McCormick Scale grades I-II) were found in 10 patients (59%), and 15(88%) were independent. Postoperative complications occurred in 4 patients (24%), two of them (12%) required revision surgery for epidural hematoma. The success rate was 94%; one patient required revision surgery for recurrent SDAVF. Better neurological condition on admission (p=0.0098) and age >60 years (p=0.0498) were the factors associated with satisfactory outcome. CONCLUSIONS Microsurgical closing of a SDAVF brings good and stable results over time. Aggressive treatment should be attempted even in cases of total loss of spinal cord function. Neurological condition before surgery and age may influence the outcome.
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Affiliation(s)
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland.
| | - Arkadiusz Nowak
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Czernicki
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Kamil Leśniewski
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, Warsaw, Poland
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Acute paraparesis and sensory loss following intravenous corticosteroid administration in a case of longitudinally extensive transverse myelitis caused by spinal dural arteriovenous fistula: case report and review of literature. Spinal Cord Ser Cases 2017; 3:17025. [PMID: 28546874 DOI: 10.1038/scsandc.2017.25] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 04/06/2017] [Accepted: 04/17/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The underlying causes of longitudinally extensive transverse myelitis (LETM) are broad and include inflammatory processes, compression and spinal dural arteriovenous fistula (SDAVF). Presenting symptoms of SDAVF are nonspecific and often go misdiagnosed. Acute clinical deterioration from SDAVF has been described following exertion or valsalva. However, deterioration has been recently recognized following steroid administration and may contribute to increased morbidity. CASE PRESENTATION We describe a 63-year-old woman with a 2-year history of intermittent lower extremity numbness and back pain, lumbar stenosis, who presented with subacute worsening of symptoms following a course of oral steroids for an upper respiratory infection. Initial whole-spine imaging was concerning for LETM and lumbar puncture was concerning for an inflammatory process. The patient was treated with intravenous (IV) methylprednisolone, after which she developed acute onset bilateral lower extremity paraparesis with a sensory level. Angiogram confirmed the diagnosis of SDAVF and the patient was treated surgically. Post-operative course was complicated and subsequent clinical improvement has been slow with incomplete recovery to date. DISCUSSION This case illustrates the nonspecific presentation of SDAVF and the difficulty of differentiating it from other causes of LETM. It demonstrates acute clinical deterioration of SDAVF following steroid administration, a recently recognized clinical entity. The most likely mechanism is hydrostatic steroid effect coupled with iatrogenic fluid co-administration causing increased venous congestion. Previous cases have demonstrated this effect to be transient and resolves after discontinuation of steroids. This case highlights a recent association of increased morbidity following steroid administration despite definitive treatment.
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Nasr DM, Brinjikji W, Rabinstein AA, Lanzino G. Clinical outcomes following corticosteroid administration in patients with delayed diagnosis of spinal arteriovenous fistulas. J Neurointerv Surg 2016; 9:607-610. [DOI: 10.1136/neurintsurg-2016-012430] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 11/03/2022]
Abstract
Background and purposeThere have been several previously reported cases of acute progression of myelopathic symptoms in patients with spinal arteriovenous fistula (SAVF) treated with intravenous methylprednisolone. This usually occurs during or immediately following steroid administration. We examined a small case series of patients with SAVF treated with epidural, oral, or intravenous steroids to determine the association between steroid administration and clinical outcomes in these patients.MethodsFollowing Institutional Review Board approval, we conducted a retrospective review of patients with angiographically-confirmed SAVF who received intravenous, oral, or epidural corticosteroids for treatment of their symptoms. We studied patient-reported motor and sensory function following steroid administration using both the modified Rankin Scale and the Aminoff Motor Disability Scale.ResultsTwenty-one patients with SAVF were included in this study. Thirteen patients (61.9%) had intravenous methylprednisolone administered, four patients (19.0%) had epidural steroid injections, and six patients (28.6%) had oral prednisone. Among patients who received intravenous methylprednisolone, seven (53.8%) reported acute worsening of symptoms during or immediately following steroid administration. Among the patients receiving epidural steroids, none reported worsening and one patient reported short-term relief. Among the patients receiving oral steroids, one reported acute worsening of symptoms. Worsened deficits did not consistently resolve after steroid discontinuation.ConclusionsOur study suggests that intravenous methylprednisolone can cause immediate worsening of motor and sensory symptoms when administered to patients with SAVF. Steroid administration should be avoided in patients with a myelopathy secondary to an untreated SAVF because neurological worsening may not be fully reversible.
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Koerts G, Vanthuyne V, Delavallee M, Rooijakkers H, Raftopoulos C. Spinal dural arteriovenous fistula presenting with paraplegia following lumbar puncture. J Neurosurg Spine 2013; 19:57-60. [DOI: 10.3171/2013.3.spine12888] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal dural arteriovenous fistulas are rare lesions with an annual incidence of 1 per 100,000 population. In patients with this disease, an abnormal vascular dural shunt exists between a dural branch of a segmental artery and a subdural radicular vein that drains the perimedullary venous system, leading to venous hypertension and secondary congestive myelopathy. Generally, patients present with progressive paraparesis, urinary disturbances, and gait ataxia. In this report the authors describe a 61-year-old woman with a spinal dural arteriovenous fistula who developed an acute paraplegia after a nontraumatic lumbar puncture. The possible underlying mechanisms and treatment options are discussed.
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Strowd RE, Geer C, Powers A, Abou-Zeid N. A unique presentation of a spinal dural arteriovenous fistula exacerbated by steroids. J Clin Neurosci 2012; 19:466-8. [DOI: 10.1016/j.jocn.2011.07.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 07/06/2011] [Indexed: 10/14/2022]
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Hsaini Y, Semlali A, Jidal M, Bourazza A. Tétraplégie ascendante révélant une fistule artérioveineuse durale intracrânienne de type V. Presse Med 2010; 39:1105-8. [DOI: 10.1016/j.lpm.2010.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 04/12/2010] [Accepted: 04/21/2010] [Indexed: 11/15/2022] Open
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Lee CS, Pyun HW, Chae EY, Kim KK, Rhim SC, Suh DC. Reversible aggravation of neurological deficits after steroid medication in patients with venous congestive myelopathy caused by spinal arteriovenous malformation. Interv Neuroradiol 2009; 15:325-9. [PMID: 20465916 DOI: 10.1177/159101990901500310] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 08/18/2009] [Indexed: 11/15/2022] Open
Abstract
SUMMARY Steroids are empirically used to medicate patients with myelopathy of unknown etiology. We report the reversible aggravation of neurological status after steroid administration in a patient with venous congestive myelopathy (VCM). We retrospectively evaluated 36 patients with angiographically confirmed spinal arteriovenous malformation (SAVM) from a prospectively collected neurointerventional database. We evaluated steroid medication and neurological aggravation using Aminoff grading and analyzed using Fisher's exact test whether steroid medication is related to neurological aggravation and spinal cord edema as demonstrated on MR T2-WI. Among 26 patients who had been treated with steroids, ten had aggravated neurological deficits. The aggravation in these ten patients was related to the steroid medication (P = 0.039 in all patients) and only marginally to VCM with spinal cord edema as seen on T2-WI (P = 0.074). Aggravation caused by using a high intravenous dose (250-1000 mg) of methylprednisolone or dexamethasone at 8-20 mg/day slowly decreased after stopping the steroid medication. Steroids were reversibly detrimental in patients with VCM caused by SAVM. A history of neurological aggravation after the use of steroids may suggest the diagnosis of SAVM associated with VCM.
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Affiliation(s)
- C-S Lee
- Departments of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center; Seoul, Korea -
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Cabrera M, Paradas C, Márquez C, González A. Acute paraparesis following intravenous steroid therapy in a case of dural spinal arteriovenous fistula. J Neurol 2008; 255:1432-3. [PMID: 18758891 DOI: 10.1007/s00415-008-0943-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 01/16/2008] [Accepted: 02/13/2008] [Indexed: 11/29/2022]
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