Venous congestive myelopathy: a mimic of neoplasia

Magnetic Resonance Spectroscopy Facilitates the Understanding of the Pathophysiology of Cerebellar Arteriovenous Malformations

Magnetic resonance spectroscopy (MRS) is a non-invasive imaging technique that facilitates the observation of tissue metabolism. It holds potential not only in research but also in clinical settings for understanding pathophysiology. This report presents the case of a 73-year-old woman with cerebellar arteriovenous malformation (AVM) in which MRS contributed to understanding the condition. Preoperative magnetic resonance imaging revealed T2/fluid-attenuated inversion recovery hyperintensity in the right cerebellar hemisphere. MRS of the same site showed an increase in lactate (Lac) and a decrease in N-acetylaspartate (NAA) levels. Through examination, she was diagnosed with a micro-AVM. Although transarterial embolization was performed on another day, completely occluding the shunt and treating the AVM, MRS showed a persistent decrease in NAA and elevated Lac levels and suggested that irreversible brain tissue damage had occurred due to the progression of venous congestion. The use of MRS in patients with suspected cerebellar AVMs allows for evaluating the degree of brain damage due to venous congestion, providing valuable insights for treatment decisions, in addition to evaluating treatment outcomes.

Foix-Alajouanine Syndrome: A Case Report

Foix-Alajouanine syndrome is a rare form of presentation of an arteriovenous malformation of the spinal cord that causes myelopathy in the thoracic and lumbar medullary segments. We present the case of a 46-year-old female who suffered from weakness in the lower limbs with sensation loss, low back pain, urinary incontinence, and constipation. The magnetic resonance image T2 sequence of the thoracic spine from T6 to T11 revealed abnormally hypointense signals in the posterior epidural region caused by larger arteries. A spinal digital subtraction angiography was useful to diagnose a right perimedullary fistula with venous drainage, which was satisfactorily embolized. The key to suspecting this diagnosis is the presence of dilated vessels in the posterior epidural space, which are evident in T2 and short tau inversion recovery (STIR)-weighted sequences. Physicians often misdiagnose Foix-Alajouanine syndrome, resulting in potential delays in care. Neurosurgeons can use surgery or endovascular embolization to treat this condition.

Arteriovenous malformations of the filum terminale: clinical characteristics, angioarchitecture, and management of a rare spinal vascular pathology

OBJECTIVE

The goal of this study was to describe clinical and neuroradiological features of arteriovenous malformations of the filum terminale (FT AVMs) and to present the authors’ diagnostic and therapeutic management in this rare disease.

METHODS

The presented cases were retrieved from a retrospectively collected database of all spinal vascular malformations treated between June 1992 and December 2021 at the Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital Aachen. Pretreatment and follow-up clinical and neuroradiological data were analyzed for this study.

RESULTS

Data in 15 patients with FT AVM with a mean age of 60 years were included, with an overall incidence of FT AVM of 19% among all spinal AVMs in our cohort. Twelve of 15 (80%) patients were men. Nonspecific but typical clinical and MR findings of thoracolumbar congestive myelopathy were found in all patients. Spinal MR angiography, performed in 10 patients, identified in all cases the arterialized FT vein as well as a lumbar/lumbosacral location of an AV shunt. Digital subtraction angiography (DSA) showed an arterial supply solely via the FT artery in 12/15 (80%) patients and via an additional feeder from the lumbosacral region in the other 3/15 (20%) patients. All patients were treated surgically. During 1-year follow-up, 2 patients presented with recurrent FT AVM due to further arterial supply from the lumbosacral region, and were treated surgically. Neurological status was improved in all patients within the 1-year follow-up, with marginal further changes during long-term follow-up.

CONCLUSIONS

Congestive myelopathy is the major pathological mechanism of symptoms in these patients, with no evidence for intradural bleeding. Missing the presence of possible multiple arterial supply of FT AVM during DSA may result in misdiagnosis and/or insufficient treatment. Due to the frequently prolonged course of FT artery, resection of the FT AVM may be a favorable treatment modality in comparison with endovascular treatment. Follow-up examinations are obligatory within the first 3 years after treatment, and further MR angiography and DSA examinations are indicated if congestive myelopathy persists.

Acute neurological deterioration after surgical interruption of spinal dural arteriovenous fistulas: clinical characteristics, possible predictors, and treatment. Patient series

BACKGROUND

Acute neurological deterioration develops paradoxically in some patients after obliteration of a spinal dural arteriovenous fistula (SDAVF), with thrombosis of the spinal cord veins as its primary cause. The authors aimed to clarify the clinical and radiological characteristics of acute deterioration to identify high-risk patients. They also discussed the optimal treatment for this complication.

OBSERVATIONS

Ten patients with SDAVF presenting with congestive myelopathy who received microsurgical interruption were retrospectively reviewed. Severe myelopathy developed in three patients on postoperative days 1 to 3. Anticoagulation therapy was effective; however, discontinuing anticoagulants under residual spinal cord congestion caused redeterioration. These patients were characterized by significantly extended transit time on angiography and significant prolongation of spinal cord congestion. Acute deterioration exhibited a strong correlation with transit time (coefficient, 0.825; p = 0.006) and a strong correlation with spinal cord edema before surgery (coefficient, 0.656; p = 0.040).

LESSONS

Acute deterioration after SDAVF treatment is likely to develop in patients with severe venous outflow impairment. Its pathology is prolonged spinal cord congestion caused by postoperative venous thrombosis and preexistent severe venous outflow impairment. Anticoagulation treatment should be continued for patients with acute deterioration until the resolution of spinal cord congestion is confirmed with magnetic resonance imaging.

Spinal arteriovenous malformations causing Foix-Alajouanine syndrome, a case report and review of the literature

Foix-Alajouanine syndrome is a rare progressive form of spinal AVM predominantly affecting the lower thoracic and/or lumbosacral regions. This study aims to describe the imaging findings of spinal AVM causing Foix-Alajouanine syndrome and to review the literature. We present a 48-year-old man with progressive back pain, leg weakness, and gait imbalance without urinary retention. We discuss the clinical and imaging findings and the significance of MRI in establishing the diagnosis. A definitive diagnosis of spinal AVM requires radiographic demonstration of the vascular anomaly. Despite the high sensitivity of angiography for the diagnosis of spinal AVM, the result of the study may be inconclusive and/or negative. The key MRI findings are the presence of abnormally dilated perimedullary vessels with signal voids from a high-velocity flow on T1 and T2 weighted images.

Vascular Myelopathies

PURPOSE OF REVIEW

Neurologists should be able to identify clinical and neuroimaging features that distinguish vascular disorders from other causes of myelopathy.

RECENT FINDINGS

Although certain clinical features suggest a vascular etiology in acute and chronic myelopathy settings, accurate MRI interpretation within the clinical context is key. Recent studies have shown vascular myelopathies are frequently misdiagnosed as transverse myelitis, and recognition of this diagnostic pitfall is important. Many different vascular mechanisms can cause myelopathy; this article provides a comprehensive review that simplifies disease categories into arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage.

SUMMARY

It is important to recognize and manage vascular disorders of the spinal cord as significant causes of acute, subacute, and progressive myelopathy.

When the Problem Became the Solution

We present a unique case where a young man developed subtle cavernous sinus thrombosis (CST) due to underlying hypercoagulable state. He also had coexisting frontal lobe brain dural arteriovenous fistula (bdAVF). After CST developed, venous drainage from the optic nerve was redirected into the frontal lobe which was already under high venous pressure because of preexisting bdAVF. This caused backflow of venous blood into the optic nerve causing massive persistent optic nerve head swelling. Presumed acute venous hypertension event within bdAVF caused frontal mass effect presenting as seizure leading to thrombosis of bdAVF.

Localized atrophy of the pontine base as a sequela of prolonged ischemia: Report of an autopsy case

An 80-year-old man with a history of diabetes mellitus and hypertension died of a progressive neurological disorder characterized by truncal ataxia, extraocular movement disturbance, and muscular rigidity. Neuroradiological examination showed progressive atrophy restricted to the pontine base. Autopsy revealed localized atrophy of the pontine base, in which both neurons and nerve fibers were lost, especially in the central region. Medium-sized and small arteries in the parenchyma of the pontine base showed marked fibro-hyalinous thickening of the walls with luminal stenosis, but no distinct tissue defect as seen in lacunar infarct was observed. Perivascular lymphocytic infiltration was mostly absent, and reactive astrocytic proliferation was weak. The pontine tegmentum, midbrain, and medulla oblongata were well preserved. Localized atrophy of the pontine base is a rare pathological condition, and its pathogenesis in the present case can be best explained by a prolonged ischemic state (hypoperfusion) due to marked sclerotic changes of perforating arteries. It is unique that the lesions were restricted to the pontine base and the formation of lacunas was not observed. Localized metabolic derangement resembling that seen in central pontine myelinolysis might have also contributed to the pathogenesis of this peculiar localized atrophy.

The clinical value of venous drainage in patients with spinal dural arteriovenous fistula

BACKGROUND

Spinal dural arteriovenous fistulas (sdAVF) with rapid deterioration are a known clinical phenomenon but have been rarely reported in the past. Clinical and radiologic features of these fistulas are analyzed for this study.

MATERIAL AND METHODS

We retrospectively reviewed our medical records for sdAVF patients who were treated in our center between 2006 and 2017. Our cohort was dichotomized in two groups; a) patients with acute/ subacute onset and rapid deterioration within a period of ≤6 months, b) patients with chronic progressive deterioration within a period of >6 months. MR findings at time of diagnosis were re-evaluated. All patients were treated microsurgically. Follow-up data were included.

RESULTS

Data of forty patients were available for this study. Rapid deterioration was observed in 13/40 (32.5%) patients. AL-score at time of diagnosis did not differ between both groups (3.2 ± 1.2 vs 3 ± 2, p = .78). Patients with rapid deterioration showed significantly more prominent arterialized perimedullay veins at time of diagnosis (p < .05). At the last follow-up (53 ± 3 months), patients with rapid deterioration improved up to one point on AL-scores (from 3.2 ± 1.4 to 2 ± 1.6) and those with chronic progressive deterioration were unchanged (from 3 ± 1.6 to 3 ± 1.7).

CONCLUSION

Patients with rapid deterioration in our group (32.5%) presented with a significantly more prominent appearance of the arterialized perimeduallry veins. This may reflect, in the earlier phase of the disease, a better compensation of the venous hypertension as well as the associated venous outlet disorder of the spinal cord. This may also explain the better outcome of these patients.

Spinal Epidural Arteriovenous Fistula with Perimedullary Venous Reflux: Clinical and Neuroradiologic Features of an Underestimated Vascular Disorder

BACKGROUND AND PURPOSE

The purpose of this study was to discuss the clinical and radiologic characteristics of spinal epidural arteriovenous fistulas (SEAVF) and demonstrate their specific angiomorphology in a single-center series.

MATERIALS AND METHODS

Thirteen consecutive patients were diagnosed with SEAVF at RWTH Aachen University Hospital between 2006 and 2018 and were included in this study. All patients had MR imaging and DSA before treatment; 10 of these 13 patients received contrast-enhanced MRA (CE-MRA).

RESULTS

The mean patient age was 72 ± 8 years. Paraparesis was present in 12 (92%) patients. Sphincter dysfunction and sensory symptoms were observed in 7 (54%) and 6 (46%) patients, respectively. The mean duration of symptoms was 6 ± 8 months. Congestive myelopathy on MR imaging was present in all patients. Prominent arterialized perimedullary veins were demonstrated in only 3 cases. CE-MRA revealed arterialized perimedullary veins and an arterialized epidural pouch in 9/10 (90%) patients, mostly located ventrolaterally. DSA demonstrated a multisegmental extension of the arterialized ventrolateral epidural pouch in 6 (46%) cases. An intradural radicular drainage vein was localized distant from the original fistula point in 3 (23%) patients.

CONCLUSIONS

Congestive myelopathy with an acute/subacute clinical course was the dominant finding in spinal epidural arteriovenous fistulas. CE-MRA is a powerful diagnostic tool for identifying arterialized perimedullary veins as well as an arterialized epidural pouch. While arterialized perimedullary veins frequently present with only mild enlargement and elongation in spinal epidural arteriovenous fistulas, the arterialized epidural pouch is frequently located ventrolaterally and may extend over several vertebral levels. DSA remains the criterion standard to precisely visualize a spinal epidural arteriovenous fistula and its intradural radicular drainage vein, which may be located distant from the fistulous point.

Feasibility of Neurorehabilitation Using a Hybrid Assistive Limb for Patients Who Underwent Spine Surgery

Recent studies of robotic rehabilitation have demonstrated its efficacy for neurological disorders. However, few studies have used the Hybrid Assistive Limb (HAL) during the early postoperative stage of spine disorders. We aimed to evaluate the safety and efficacy of HAL treatment during the early postoperative period for spine disorder patients. We retrospectively identified patients who underwent spine surgery and who could complete HAL treatment. We evaluated the 10-m walking test (10MWT), the modified Gait Abnormality Rating Scale (GARS-M), Barthel Index (BI), and the walking index for spinal cord injury II (WISCI II) score results before and after robotic rehabilitation. Clinical outcomes were compared after treatment. We included nine patients with various spine problems. After HAL treatment, the speed during the 10MWT significantly improved from 64.1 ± 16.0 to 74.8 ± 10.8 m/min, and the walking cadence decreased from 102.7 ± 17.6 to 92.7 ± 10.9 steps/min. The BI score also improved from 83.3 ± 16.0 to 95.6 ± 5.8, and the WISCI II score improved from 19.7 ± 0.5 to 20.0 ± 0.0. Furthermore, the total GARS-M score improved from 6.0 ± 5.7 to 2.3 ± 3.3. The maximum angles of the trunk swing were improved from 2.2 ± 1.9 to 1.2 ± 0.9 degrees. Neurorehabilitation therapy using HAL for spinal surgery patients was considered feasible following spine surgery.

Temporal evolution of a patient with a spinal dural arteriovenous fistula on serial MRI

Introduction

A spinal dural arteriovenous fistula is a rare type of vascular malformation. If left untreated, these fistulas can result in significant neurological deficits secondary to spinal cord infarct or hemorrhage.

Case presentation

A 70-year-old female with a longstanding history of episodic progressive bilateral lower extremity weakness and sensory disturbances was previously misdiagnosed with multiple sclerosis. Imaging revealed a T2 signal change from T7 to the conus with associated signal change and she subsequently underwent a T10-L1 laminectomy for clip ligation of a spinal dural arteriovenous fistula. Here we present the clinical and radiographic progression of one patient with a spinal dural arteriovenous fistula.

Discussion

Spinal dural arteriovenous fistulas are a rare but treatable cause of myelopathy, so it is important to understand its natural progression and radiologic findings as it is frequently misdiagnosed.

Dural Arteriovenous Fistula Mimicking a Supratentorial Tumor

BACKGROUND

The pathophysiology of dural arteriovenous fistulas (dAVF) is not fully understood. Retrograde venous flow can lead to venous congestion and disruption of the blood-brain barrier, resulting in diffuse contrast enhancement.

CASE DESCRIPTION

We present the case of a patient with a supratentorial dAVF associated with a solid, tumor-appearing, corticosubcortical contrast-enhancing lesion. Surgical occlusion of the dAVF was followed by complete regression of the contrast-enhancing lesion. Histologic analysis of the lesion showed normal brain tissue.

CONCLUSIONS

This case report highlights how venous congestion is an important differential diagnosis in contrast-enhancing lesions associated with dAVF and how it should be taken in consideration to avoid radiologic misdiagnoses and unnecessary treatment.

The pathophysiology of venous hypertensive myelopathy—study of an animal model

Object

The authors undertook this study to establish an animal model to investigate the pathophysiological changes of venous hypertensive myelopathy (VHM).

Methods

This study was a randomized control animal study with blinded evaluation. The VHM model was developed in 24 adult New Zealand white rabbits by means of renal artery and vein anastomosis and trapping of the posterior vena cava; 12 rabbits were subjected to sham surgery. The rabbits were investigated by spinal function evaluation, abdominal aortic angiography, spinal MRI, and pathological examination of the spinal cord at different follow-up stages.

Results

Twenty-two (91.67%) of 24 model rabbits survived the surgery and postoperative period. The patency rate of the arteriovenous fistula was 95.45% in these 22 animals. The model rabbits had significantly decreased motor and sensory hindlimb function as well as abnormalities at the corresponding segments of the spinal cord. Pathological examination showed dilation and hyalinization of the small blood vessels, perivascular and intraparenchymal lymphocyte infiltration, proliferation of glial cells, and neuronal degeneration. Electron microscopic examination showed loose lamellar structure of the myelin sheath, increased numbers of mitochondria in the thin myelinated fibers, and pyknotic neurons.

Conclusions

This model of VHM is stable and repeatable. Exploration of the sequential changes in spinal cord and blood vessels has provided improved understanding of this pathology, and the model may have potential for improving therapeutic results.

Thoracic venous congestion caused by thoracic disc herniation

We present what is to our knowledge the first reported case of thoracic disc herniation leading to venous congestive myelopathy (VCM), which was clinically and radiographically suggestive of Foix-Alajouanine syndrome (angiodysgenetic necrotizing myelopathy). In addition, we review current concepts in evaluating the etiology of VCM and discuss indications for surgery.

Histologically proven venous congestive myelopathy without concurrent vascular malformation: Case reports and review of the literature

BACKGROUND

Venous congestive myelopathy is a progressive myelopathy that is generally caused by a spinal dural arteriovenous fistula.

CASE DESCRIPTION

We report a patient with histologically confirmed venous congestive myelopathy without concurrent vascular malformations in radiological and intraoperative findings.

CONCLUSIONS

The definitive underlying etiology of this congestive myelopathy was unclear. However, this case report highlights the possibility of venous congestive myelopathy with etiology other than a dural arteriovenous fistula. Further, a systematic and elaborate examination should be undertaken to explore the underlying pathology whenever this type of spinal parenchymal lesion is detected.

Reinterpreting the magnetic resonance signs of hemodynamic impairment in the brains of multiple sclerosis patients from the perspective of a recent discovery of outflow block in the extracranial veins

Multiple sclerosis patients examined with perfusion magnetic resonance (MR) imaging techniques have been found to have patterns of abnormal blood flow. These include prolonged mean transit time, a trend toward decreased cerebral blood flow in the area of plaques, and decreased cerebral blood flow and prolonged mean transit time within normal-appearing white matter. Increased cerebral blood flow and volume and decreased mean transit time (compared with the baseline values before the relapse) were found to precede the development of plaques. In addition, susceptibility-weighted imaging utilizing deoxyhemoglobin as the contrast has revealed that venous blood in cerebral veins of multiple sclerosis patients is less deoxygenated compared with healthy controls. All these findings were traditionally interpreted as a sign of local flow disturbances mediated by inflammatory and neurodegenerative processes. However, recent findings of significant stenoses in the extracranial veins that drain the brain and spinal cord shed new light on these MR results. With the assumption that a majority, if not all, of multiple sclerosis patients exhibit such extracranial venous obstacles, the perfusion MR images of multiple sclerosis patients should be reinterpreted. Perhaps ongoing MR studies with respect to extracranial venous hemodynamics may decipher some of the unsolved puzzles related to this neurologic disease.

Reversible aggravation of neurological deficits after steroid medication in patients with venous congestive myelopathy caused by spinal arteriovenous malformation

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.

Lumbar congestive myelopathy mimicking neoplasia without concurrent vascular malformation

A 78-year-old male presented with congestive myelopathy manifesting as progressive gait disturbance following conservative therapy for lumbar spinal canal stenosis, with suspected spinal cord tumor in the conus medullaris. His past medical history was unremarkable and he was not aware of any traumatic injury in the back or infectious disease. On admission, he had clumsy hand, moderate paraparesis, significant sensory disturbance below the L5 level, and severe vesicorectal dysfunction. The deep tendon reflex was promoted in the upper extremities, but poorly induced in the lower extremities. Blood examination found no abnormalities including values of tumor markers. Cerebral, cervical, and thoracic magnetic resonance (MR) imaging revealed no contributory pathology without spondylotic change at the C3-C6 levels. Lumbar MR imaging showed fusiform swelling of the cord from the T10 to T12-L1 levels, with rimlike enhancement at the T12-L1 levels by gadolinium. The patient underwent surgery. Intraoperatively, the dorsal surface of the affected cord was pale, not swollen, and sparsely vascularized without tortuous vessels. Midline myelotomy caused escape of creamy material that was identified as necrotic neural tissue. A collapsed vessel, located on the surface of the cord, was histologically identified as a thrombosed vein. The histological findings were compatible with spinal infarction caused by congestive myelopathy. Whole craniospinal and iliac angiography performed postoperatively failed to reveal any dural and paraspinal vascular malformation. His paraparesis, sensory disturbance, and vesicorectal dysfunction improved significantly after surgery. Congestive myelopathy may be caused by various angiographically occult etiologies other than dural arteriovenous fistula.

Venous congestive myelopathy in spinal dural arteriovenous fistula mimicking neoplasia

Spinal dural arteriovenous fistulas (SDAVF) are the most common acquired arteriovenous shunts that occur in adults. By increasing venous pressure in the spinal venous system they are a cause of venous congestive myelopathy. We report the case of a patient with a SDAVF mimicking, on magnetic resonance imaging, the presence of a spinal cord tumour due to an unusual pattern of enhancement after gadolinium administration.

Venous congestive myelopathy of the cervical spinal cord: An autopsy case showing a rapidly progressive clinical course

We report a rapidly progressive myelopathy in a 74-year-old Japanese man who was admitted to our hospital with a 4-month history of progressive gait disturbance and died of pneumonia followed by respiratory failure on the 22nd day of admission. During the course of his illness, magnetic resonance imaging (MRI) revealed intramedullary lesions with edematous swelling from the medulla oblongata to the spinal cord at the level of the fourth vertebra. After administration of contrast medium, the ventral portion of the lesion was mildly and irregularly enhanced and a dilated vessel was recognized along the ventral surface of the upper cervical cord. At autopsy, ischemic changes were observed in the upper-to-middle cervical cord segments, with so-called arterialized veins in the subarachnoid space. No neoplastic lesions were found within or outside the brain and spinal cord. These pathological findings were essentially those of venous congestive myelopathy (VCM) associated with dural arteriovenous fistulae (AVF), formerly known as Foix-Alajouanine syndrome. VCM associated with dural AVF, which is now considered to be treatable in the early stages, is rare found in the cervical spinal cord. The present autopsy case, with MRI findings, provides further information that might be useful for recognition and diagnosis.

Chronic superior sagittal sinus thrombosis with phlebosclerotic changes of the subarachnoid and intracerebral veins

An autopsy case of chronic thrombotic occlusion of the superior sagittal sinus (SSS) with an unusually protracted clinical course is reported. The patient was an 84-year-old man without any predisposing conditions for thrombosis. The clinical features were atypical and were characterized by recurrent cerebral subcortical hemorrhages. The autopsy revealed a large, organized thrombus in the SSS and extensive hemorrhagic infarction of the bilateral parasagittal region of the cerebral hemispheres. The hemorrhagic infarction was comprised of the aggregation of numerous minute foci of coagulation necrosis associated with petechial hemorrhages. Marked phlebosclerotic changes were observed in the subarachnoid and intracerebral veins, which were considered to be reactive changes of the venous walls against a persistent elevation in peripheral venous pressure caused by thrombosis of the SSS.