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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; 34:639-647. [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] [MESH Headings] [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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Tian A, Cui Z, Ren J, Ren Y, Ye M, Li G, He C, Li X, Zeng G, Hu P, Ma Y, Yu J, Li J, Bian L, Yang F, Li Q, Ling F, Hong T, Sun L, Zhang H. Surgical timing and long-term outcomes in patients with severe haemorrhagic spinal cord cavernous malformations. Stroke Vasc Neurol 2024; 9:439-445. [PMID: 37949480 PMCID: PMC11420913 DOI: 10.1136/svn-2023-002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/07/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Surgical resection of the lesions remains the main treatment method for most symptomatic spinal cord cavernous malformations (SCCMs) to eliminate the occupation and associated subsequent lifelong haemorrhagic risk. However, the timing of surgical intervention remains controversial, especially for patients in the acute stage after severe haemorrhage. METHODS Patients diagnosed with SCCMs who were surgically treated between January 2002 and December 2021 were selected and retrospectively reviewed. The Modified McCormick Scale (MMS) was used to evaluate neurological and disability status. All medical information was reviewed, and all patients were followed up for at least 6 months. RESULTS A total of 279 patients were ultimately included. With regard to long-term outcomes, 110 (39.4%) patients improved, 159 (57.0%) remained unchanged and 10 (3.6%) worsened. For patients with an MMS score of 2-5 on admission, in univariate and multivariate analyses, a ≤6 weeks period between onset and surgery (adjusted OR 3.211, 95% CI 1.504 to 6.856, p=0.003) was a significant predictor of improved MMS. Among 69 patients who first presented with severe haemorrhage, undergoing surgery within 6 weeks of the onset of severe haemorrhage (adjusted OR 4.901, 95% CI 1.126 to 21.325, p=0.034) was significantly associated with improvement of MMS score. CONCLUSION Surgical timing can influence the long-term outcome of SCCMs. For patients with symptomatic SCCMs, especially those with severe haemorrhage, early surgical intervention within 6 weeks can provide more benefit.
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Affiliation(s)
- An Tian
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ziwei Cui
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jian Ren
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yeqing Ren
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, United Family Healthcare, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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Hu X, Yuan Z, Liang K, Chen M, Zhang Z, Zheng H, Cheng G. Application of Spinal Subtraction and Bone Background Fusion CTA in the Accurate Diagnosis and Evaluation of Spinal Vascular Malformations. AJNR Am J Neuroradiol 2024; 45:351-357. [PMID: 38360787 DOI: 10.3174/ajnr.a8112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/02/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND PURPOSE Accurate pretreatment diagnosis and assessment of spinal vascular malformations using spinal CTA are crucial for patient prognosis, but the postprocessing reconstruction may not be able to fully depict the lesions due to the complexity inherent in spinal anatomy. Our purpose was to explore the application value of the spinal subtraction and bone background fusion CTA (SSBBF-CTA) technique in precisely depicting and localizing spinal vascular malformation lesions. MATERIALS AND METHODS In this retrospective study, patients (between November 2017 and November 2022) with symptoms similar to those of spinal vascular malformations were divided into diseased (group A) and nondiseased (group B) groups. All patients underwent spinal CTA using Siemens dual-source CT. Multiplanar reconstruction; routine bone subtraction, and SSBBF-CTA images were obtained using the snygo.via and ADW4.6 postprocessing reconstruction workstations. Multiple observers researched the following 3 aspects: 1) preliminary screening capability using original images with multiplanar reconstruction CTA, 2) the accuracy and stability of the SSBBF-CTA postprocessing technique, and 3) diagnostic evaluation of spinal vascular malformations using the 3 types of postprocessing images. Diagnostic performance was analyzed using receiver operating characteristic analysis, while reader or image differences were analyzed using the Wilcoxon signed-rank test or the Kruskal-Wallis rank sum test. RESULTS Forty-nine patients (groups A and B: 22 and 27 patients; mean ages, 44.0 [SD, 14.3] years and 44.6 [SD,15.2] years; 13 and 16 men) were evaluated. Junior physicians showed lower diagnostic accuracy and sensitivity using multiplanar reconstruction CTA (85.7% and 77.3%) than senior physicians (93.9% and 90.9%, 98% and 95.5%). Short-term trained juniors achieved SSBBF-CTA image accuracy similar to that of experienced physicians (P > .05). In terms of the visualization and localization of spinal vascular malformation lesions (nidus/fistula, feeding artery, and drainage vein), both multiplanar reconstruction and SSBBF-CTA outperformed routine bone subtraction CTA (P = .000). Compared with multiplanar reconstruction, SSBBF-CTA allowed less experienced physicians to achieve superior diagnostic capabilities (comparable with those of experienced radiologists) more rapidly (P < .05). CONCLUSIONS The SSBBF-CTA technique exhibited excellent reproducibility and enabled accurate pretreatment diagnosis and assessment of spinal vascular malformations with high diagnostic efficiency, particularly for junior radiologists.
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Affiliation(s)
- Xuehan Hu
- From the Department of Radiology (X.H., Z.Y., K.L., Z.Z., G.C.), Peking University Shenzhen Hospital, Shenzhen, China
- Paul C. Lauterbur Research Center for Biomedical Imaging (X.H., H.Z.), Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences
| | - Zhidong Yuan
- From the Department of Radiology (X.H., Z.Y., K.L., Z.Z., G.C.), Peking University Shenzhen Hospital, Shenzhen, China
| | - Kaiyin Liang
- From the Department of Radiology (X.H., Z.Y., K.L., Z.Z., G.C.), Peking University Shenzhen Hospital, Shenzhen, China
| | - Min Chen
- Department of Radiology (M.C.), Southern University of Science and Technology Hospital, Shenzhen, China
| | - Zhen Zhang
- From the Department of Radiology (X.H., Z.Y., K.L., Z.Z., G.C.), Peking University Shenzhen Hospital, Shenzhen, China
| | - Hairong Zheng
- Paul C. Lauterbur Research Center for Biomedical Imaging (X.H., H.Z.), Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences
| | - Guanxun Cheng
- From the Department of Radiology (X.H., Z.Y., K.L., Z.Z., G.C.), Peking University Shenzhen Hospital, Shenzhen, China
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Xu C, Lu X, Niu X, Li J. Sacral dural arteriovenous fistula supplied by bilateral lateral sacral arteries: case report and literature review. Br J Neurosurg 2023; 37:1797-1800. [PMID: 33983105 DOI: 10.1080/02688697.2021.1916434] [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: 09/15/2020] [Accepted: 04/09/2021] [Indexed: 02/08/2023]
Abstract
Sacral dural arteriovenous fistulas (DAVFs) with bilateral arterial supplies are extremely rare. To date, only two cases with arterial supply from bilateral lateral sacral arteries (LSAs) were reported. We report a rare case of sacral DAVF with arterial supply from bilateral LSAs. A 56-year-old man presented with a 2-month history of progressive weakness and numbness in his lower extremities, along with urinary incontinence. Spinal magnetic resonance imaging (MRI) showed extensive edema of the spinal cord, vascular flow voids, and intraparenchymal enhancement. Spinal angiography revealed a spinal DAVF at the level of S1 supplied by bilateral LSAs and drained ascending into the perimedullary venous plexus. The fistula was successfully treated with endovascular embolization. Sacral DAVFs present various diagnostic and treatment difficulties because of the complex angioarchitecture. Successful management of these lesions requires a profound understanding of the variable patterns of arterial supply in this region.
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Affiliation(s)
- Conghui Xu
- Department of Radiology, Chengdu Shangjin Nanfu Hospital, Sichuan University, Chengdu, PR China
| | - Xu Lu
- Department of Radiology, Chengdu Shangjin Nanfu Hospital, Sichuan University, Chengdu, PR China
| | - Xiaodong Niu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, PR China
| | - Jin Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, PR China
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Yoshida K, Niimi Y, Kamamoto D, Fukumura M, Imai R, Nagoshi N, Akiyama T. Targeted embolisation for coexisting conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas with a varix on a shared drainer †. Br J Neurosurg 2023; 37:1200-1205. [PMID: 33034527 DOI: 10.1080/02688697.2020.1830948] [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: 06/18/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The coexistence of vascular malformations in the conus medullaris and cauda equina has been rarely reported, and the complex angioarchitecture in multiple arteriovenous lesions remains poorly understood. CASE DESCRIPTION A 17-year-old woman presented with a sudden-onset, stepwise worsening of weakness and pain in the bilateral legs. Angiography revealed conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas. One of the drainers was shared between the coexisting lesions and harboured a varix. Targeted embolisation of a fistulous point in the conus lesion was performed with precaution to prevent occluding the common drainage route, which led to symptom improvement with angiographical diminishment of the varix. CONCLUSIONS Recognising that communications between drainers can be observed in multiple spinal arteriovenous lesions is important in facilitating a safe embolisation. Cautious assessment of angiogram with fusion images of cone-beam computed tomography and volumetric T2 magnetic resonance imaging can help in establishing the diagnosis and treatment strategy.
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Affiliation(s)
- Keisuke Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan
| | - Dai Kamamoto
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Mariko Fukumura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryotaro Imai
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takenori Akiyama
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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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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Shima S, Sato S, Ryu B, Kushi K, Mochizuki T, Inoue T, Okada Y, Niimi Y. Angiographic Index for the Treatment Efficacy and Functional Outcomes of Spinal Cord Arteriovenous Shunts: the Vertebral Blush Sign. Clin Neuroradiol 2023; 33:721-727. [PMID: 36856787 DOI: 10.1007/s00062-023-01266-2] [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: 11/06/2022] [Accepted: 01/18/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND The functional outcomes in spinal cord arteriovenous shunts (SCAVSs) are usually unpredictable from current assessments of treatment results. We aimed to investigate and propose a new index marker, the vertebral blush (VB) sign, for assessing the treatment efficacy of SCAVSs. METHODS This retrospective cohort study enrolled patients diagnosed with SCAVSs between June 2012 and May 2021. The VB sign was defined as the angiographic finding of reappearance or enhanced contrast staining of the vertebral bodies fed by shunt-related arteries observed after shunt occlusion. The primary outcome was the improvement in motor/sensory disturbances or sphincter impairments within 1 year after treatment. The secondary outcome was shunt recanalization. VB sign characteristics and associations with outcomes were analyzed. RESULTS Of 65 patients with SCAVSs, 57 were eligible for VB sign assessment; among these, there were 26 with the VB sign and 31 without the VB sign. Among vascular shunts perimedullary arteriovenous fistula showed the greatest difference in prevalence rate between those with and without the VB sign (33.3%, n = 9/27 versus 10.0%, n = 3/30; P = 0.031). On multivariable logistic regression analysis, SCAVSs with the VB sign had significantly more favorable outcomes than those without the VB sign (adjusted odds ratio, 5.61; 95% confidence interval, 1.48-21.23; P = 0.01). There was no relationship between the VB sign and secondary outcomes (P = 0.35). CONCLUSION The VB sign is independently associated with functional recovery after shunt occlusion and could be an assessment tool for the treatment efficacy of SCAVSs.
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Affiliation(s)
- Shogo Shima
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan.
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan.
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
| | - Bikei Ryu
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
| | - Kazuki Kushi
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, 104-8560, Chuo-ku, Tokyo, Japan
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Wang Y, Ma Y, Song Z, Yang C, Tu T, Yang K, He C, Li G, Hu P, Sun L, Ye M, Zhang H. Clinical and prognostic features of venous hypertensive myelopathy from craniocervical arteriovenous fistulas: a retrospective cohort study. J Neurosurg 2023; 139:687-697. [PMID: 36640099 DOI: 10.3171/2022.11.jns221958] [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: 08/24/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Current knowledge about venous hypertensive myelopathy (VHM) is incomplete. This study was performed with the aim of clarifying the clinical features and outcomes of craniocervical VHM. METHODS This retrospective, single-center cohort study included 65 patients with craniocervical junction arteriovenous fistulas resulting in VHM treated in Xuanwu Hospital from January 1, 2002, to December 30, 2020. All patients underwent microsurgery or endovascular treatment. The primary outcome was neurological function assessment using the Japanese Orthopaedic Association (JOA) scale, modified Aminoff-Logue Scale (mALS), and Venous Hypertensive Myelopathy Scale (VHMS). The secondary outcomes were recurrences and postoperative adverse events. Pearson linear regression and receiver operating characteristic curves were used to evaluate the relationships among the three scales. Kaplan-Meier and multivariate logistic regression analyses were performed to predict outcomes. RESULTS The mean patient age was 57.4 ± 11.4 years, and 88% of patients were male. The 1-year follow-up rate was 83.1%, and the 5-year follow-up rate was 50.8%. The VHMS was correlated with the JOA (R2 = 0.6722) and mALS (R2 = 0.7399) and increased the assessment accuracy by approximately 20% when compared with the other two scales. Overall, 25.9% of patients experienced delayed neurological decline beyond the 1-year follow-up. Further logistic regression suggested that age > 65 years was an independent predictor (OR 7.831, 95% CI 1.090-56.266; p = 0.041). Embolic recanalization and new bilateral symmetry feeders were the major reasons for recurrence. Recurrence increased the risk of adverse events after the second surgery (OR 20.455, 95% CI 1.170-357.320; p = 0.039). CONCLUSIONS CCJ AVFs resulting in VHM are a rare but deadly complication, and providers should be cautious of age-related delayed neurological decline and strive for a one-time anatomical cure.
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Affiliation(s)
- Yinqing Wang
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
- 2China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing; and
| | - Yongjie Ma
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
- 2China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing; and
| | - Zihao Song
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Chengbin Yang
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Tianqi Tu
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Kun Yang
- 3Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuan He
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Guilin Li
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Peng Hu
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Liyong Sun
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Ming Ye
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
| | - Hongqi Zhang
- 1Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing
- 2China International Neuroscience Institute (China-INI), Xuanwu Hospital, Capital Medical University, Beijing; and
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9
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Cao L, Feng Y, Yu J, Ma Y, Zhang M, Yao X, Liu J, Ye M, He C, Li G, Hong T, Ling F, Lu J, Zhang H. High diagnostic performance of time-resolved MR angiography in spinal arteriovenous shunts. Eur J Radiol 2023; 161:110755. [PMID: 36868062 DOI: 10.1016/j.ejrad.2023.110755] [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: 09/26/2022] [Revised: 01/20/2023] [Accepted: 02/21/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND AND PURPOSE In comparison with the limited efficacy of conventional MR imaging and the invasiveness of catheter-based digital subtraction angiography (DSA), time-resolved MR angiography (TR-MRA) has been proposed as a promising examination for early diagnosis of spinal arteriovenous shunts (SAVSs). This paper aims to investigate the diagnostic performance of TR-MRA with scan parameters optimized for SAVSs evaluation in a large number of patients. METHODS One hundred patients with suspected SAVSs were enrolled. Each patient underwent preoperative TR-MRA with optimized scan parameters followed by DSA. The presence or absence of SAVS, the types and the angioarchitecture of SAVSs in the TR-MRA images were diagnostically analyzed. RESULTS Among the final 97 patients, 80 cases (82.5 %) were diagnosed and classified by TR-MRA as spinal cord arteriovenous shunts (SCAVSs; n = 22), spinal dural arteriovenous shunts (SDAVSs; n = 48), and spinal extradural arteriovenous shunts (SEDAVSs; n = 10). The agreement for classifying SAVSs between TR-MRA and DSA was excellent (κ = 0.91). The sensitivity, specificity, PPV, NPV, and accuracy of TR-MRA for the diagnosis of SAVSs were 100 % (95 % CI, 94.3-100.0 %), 76.5 % (95 % CI, 49.8-92.2 %), 95.2 % (95 % CI, 87.6-98.5 %), 100 % (95 % CI, 71.7-100.0 %), and 95.9 % (95 % CI, 89.9-98.4 %). The accuracy rates of TR-MRA for the detection of feeding arteries were 75.9 %, 91.7 %, and 80.0 % for SCAVSs, SDAVSs, and SEDAVSs respectively. CONCLUSION Time-resolved MR angiography showed excellent diagnostic performance for SAVSs screening. Additionally, this method can classify SAVSs and identify feeding arteries in SDAVSs with high diagnostic accuracy.
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Affiliation(s)
- Lizhen Cao
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of MRI and Brain Informatics, Beijing, China
| | - Yueshan Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Mo Zhang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of MRI and Brain Informatics, Beijing, China
| | - Xinyu Yao
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of MRI and Brain Informatics, Beijing, China
| | - Jiabin Liu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of MRI and Brain Informatics, Beijing, China
| | - Ming Ye
- 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; Beijing Key Laboratory of MRI and Brain Informatics, Beijing, China
| | - GuiLin Li
- 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
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Key Laboratory of MRI and Brain Informatics, Beijing, China.
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China.
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10
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Xu JK, Ye M, Yu JX, Zhang HQ. Filum terminale arteriovenous shunt with nidus structure: a report of rare condition and treatment consideration. Int J Neurosci 2023; 133:492-495. [PMID: 33931000 DOI: 10.1080/00207454.2021.1924708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND In the literature, filum terminale arteriovenous shunts (FTAVSs) always feature a single shunt point. Nidus-type FTAVSs have rarely been reported, and the best treatment strategy is unclear. This is a report of one exceptional case of a nidus-type FTAVS and surgical treatment of the lesion. CASE DESCRIPTION The patient suffered from cauda equina syndrome for 9 months. Magnetic resonance imaging and spinal angiography revealed a nidus-type FTAVF at the L2 level. Surgical resection was performed in the hybrid operating room, and the nidus was completely resected with the assistance of intraoperative methylene blue angiography and neurophysiological monitoring. The postoperative neurological function was stable. CONCLUSIONS A nidus-type arteriovenous shunt could originate from the FT, and in such cases, complete surgical resection with intraoperative neurophysiological monitoring in a hybrid operating room should be suggested.
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Affiliation(s)
- Jian-Kun Xu
- Radiation Oncology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Jia-Xing Yu
- 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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11
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Ling F, Zeng G, Liu Y. Vascular Malformations of the Spinal Cord in Children. Adv Tech Stand Neurosurg 2023; 48:385-426. [PMID: 37770693 DOI: 10.1007/978-3-031-36785-4_15] [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] [Indexed: 09/30/2023]
Abstract
Vascular malformation of the spinal cord in children is a rare and complicated disease spectrum. We will start from the basic spinal cord vascular anatomy and the controversial classification of this kind of disease. Then, we will elaborate the clinical manifestations, diagnostic imaging and treatment of pediatric spinal vascular malformations based on the practical experience of our center and from literature.
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Affiliation(s)
- Feng Ling
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yutong Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
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12
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Su X, Fan X, Ma Y, Wang J, Wang Y, Zhang H. Diagnosis and Treatment of a Dural Arteriovenous Fistula Involving the Superior Petrosal Vein. World Neurosurg 2022; 167:e648-e655. [PMID: 36028105 DOI: 10.1016/j.wneu.2022.08.065] [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: 06/18/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE A dural arteriovenous fistula involving the superior petrosal vein (SPV DAVF) is an extremely rare condition. Therefore, its clinical presentation, imaging characteristics, treatment methods, and risk factors remain unclear. In this study, we discuss and analyze the aforementioned features of an SPV DAVF. METHODS We retrospectively reviewed 30 patients with SPV DAVFs, with a 1-year follow-up rate of 96.67% (29 of 30). The neurological function of the patients was assessed using the modified Aminoff-Logue scale and the modified Rankin Scale score. The risk factors before and after treatment were established using univariate and multivariate logistic regression analyses. Additionally, treatments involving 3 distinct SPV DAVF drainage patterns were presented. RESULTS Of the 30 patients, 24 were men (80.0%). Besides, the angiography images were reexamined 12 months after surgery. Univariate analyses indicated that the extent of edema (odds ratio 1.889, 95% confidence interval 1.132-3.154) and the number of draining veins (≤2) (odds ratio 10.833, 95% confidence interval 1.961-59.834) were risk factors for pretreatment modified Rankin Scale score ≥3. However, multivariate analyses revealed no statistically significant differences (P = 0.051, P = 0.055). Following the multivariate analyses, steroid pulse (odds ratio 12.153 95% confidence interval 1.080-136.772) was found to be the only significant risk factor for post-treatment difference between pretreatment and 1-year follow-up modified Rankin Scale score ≥2. CONCLUSIONS A DAVF with SPV drainage is an uncommon type of intracranial vascular malformation. Most lesions involve the brain stem or high cervical spinal cord, thereby posing a higher risk of disability or death. Moreover, neuronal damage from persistent venous hypertension is permanent. Therefore, precise diagnosis and timely treatment are key to a good patient prognosis.
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Affiliation(s)
- Xin Su
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xinxin Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiachen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yinqing Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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13
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Shen Y, Wang Z, Yang X, Zheng L, Wen M, Han Y, Li X, Zhang L, Wang J, You J, Jiang C, Su L, Fan X, Wang D. Novel classification for simple peripheral arteriovenous malformations based on anatomic localization: Prevalence data from the tertiary referral center in China. Front Cardiovasc Med 2022; 9:935313. [PMID: 35942181 PMCID: PMC9356220 DOI: 10.3389/fcvm.2022.935313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background In absence of the large-sample study of simple peripheral arteriovenous malfomations (pAVM), we aimed to perform the epidemiological analysis of over 1,000 simple pAVM patients from our center in the past 5 years, and establish a novel classification based on the anatomical localization of the primary lesion. Results Between March 27, 2016, and March 31, 2021, Chinese patients who were diagnosed with simple pAVM were taken into account. Those who suffered from simple arteriovenous malformations of the central nervous system (cnsAVM), combined types of AVM, and syndromes, such as CLOVES syndrome, etc. were all excluded from this study. A total of 1,070 simple pAVM patients were screened out. All of the simple pAVM patients were diagnosed by clinical manifestations and imaging examinations. Demographic data were obtained from the National Bureau of Statistics of China. The 5-year prevalence of simple pAVM was about (2.15–6.60) /1,000,000 population. The male-female ratio was approximately 1.22:1. The pAVM inpatients that were included in the age group of 21~30 years old had the highest constituent ratio (P = 0.01). The classification included four groups: Type I (primarily occurring in soft tissue); Type II (primarily occurring in bone); Type III (primarily occurring in the viscus) and Type IV (simple pAVM coexisting with CNS lesions). There were two subtypes of Type I: the A subtype (involving one major anatomical region) and the B subtype (involving two or more major anatomical regions); two subtypes of Type II: the A subtype (the cortex was intact) and the B subtype (the lesion had broken through the cortex). Generally, 657 patients were classified as Type IA (61.4%), 232 patients were Type IB (21.7%), 82 patients were Type IIA (7.7%) and 79 were categorized as Type IIB (7.4%); the number of patients who had Type III and Type IV pAVM were 9 (0.8%) and 11 (1.0%), respectively. The clinical manifestations and diagnostic standards for each type were also systematically summarized. Conclusions Prevalence data for simple pAVM were analyzed, and a novel classification was proposed based on the anatomy of the lesions. The present work was expected to facilitate the diagnosis of simple pAVM in clinical works.
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14
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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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15
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Ren J, Jiang N, Bian L, Dmytriw AA, Zeng G, He C, Sun L, Li X, Ma Y, Yu J, Li G, Ye M, Hu P, Li J, Yang F, Li Q, Ling F, Zhang H, Hong T. Natural History of Spinal Cord Cavernous Malformations: A Multicenter Cohort Study. Neurosurgery 2022; 90:390-398. [PMID: 35049523 DOI: 10.1227/neu.0000000000001842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The natural history of spinal cord cavernous malformations (SCCMs) remains relatively unclear. OBJECTIVE To investigate the natural history for hemorrhagic risks and neurological outcomes, as well as relevant predicting factors, of SCCMs. METHODS All patients between 2002 and 2019 with diagnosis of SCCMs were identified retrospectively. An observational study of patients with conservative management was performed to reveal the natural history of SCCMs. RESULTS We identified 305 patients in the full cohort, including 126 patients who were conservatively treated for at least 6 months (median observational period, 24.0 months). Forty-five hemorrhage events occurred during 527 person-years of follow-up, yielding an annual hemorrhage rate of 8.5% per person-year. The 1-, 2-, and 5-year cumulative risks of hemorrhage were 13.9%, 26.1%, and 35.1%, respectively. Prior hemorrhage (hazard ratio [HR] = 12.948, P = .012) and pediatric patients (HR = 2.841, P = .031) were independent predictors of hemorrhage in the long-term follow-up. Familial form (adjusted odds ratio [OR] = 30.695, P = .010) and subsequent hemorrhage events (adjusted OR = 16.333, P = .000) were independent risk factors for worsening of neurological function, and baseline neurological status (adjusted OR = 78.984, P = .000) and presence of subsequent hemorrhage (adjusted OR = 9.611, P = .001) were significantly associated with neurological outcomes. CONCLUSION The natural history of SCCMs varies. Baseline characteristics, such as pediatric patients, familial form, and baseline neurological status, as well as prior and subsequent hemorrhagic events, significantly affect the natural history of the SCCMs, which prompts a differentiated treatment strategy.
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Affiliation(s)
- Jian Ren
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gao Zeng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Jingwei Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Qianwen Li
- Department of Radiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China International Neuroscience Institute, Beijing, China
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16
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Marcellino C, Zalewski NL, Rabinstein AA. Treatment of Vascular Myelopathies. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Feng Y, Yu J, Xu J, He C, Bian L, Li G, Ye M, Hu P, Sun L, Jiang N, Ling F, Hong T, Zhang H. Natural History and Clinical Outcomes of Paravertebral Arteriovenous Shunts. Stroke 2021; 52:3873-3882. [PMID: 34412511 DOI: 10.1161/strokeaha.120.033963] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Paravertebral arteriovenous shunts (PVAVSs) are rare. Whether the intradural venous system is involved in drainage may lead to differences in clinical characteristics through specific pathophysiological mechanisms. This study aims to comprehensively evaluate the natural history and clinical outcomes of PVAVSs with or without intradural drainage. METHODS Sixty-four consecutive patients with PVAVSs from 2 institutes were retrospectively reviewed. Lesions were classified as type A (n=28) if the intradural veins were involved in drainage; otherwise, they were classified as type B (n=36). The clinical course from initial presentation to the last follow-up was analyzed. RESULTS The patients with type A shunts were older at presentation (52.5 versus 35.5 years, P<0.0001) and more likely to have lower spinal segments affected than patients with type B PVAVSs (67.8% versus 13.9%, P=0.00006). After presentation, the deterioration rates related to gait and sphincter dysfunction were significantly higher in patients with type A than type B shunts (gait dysfunction: 71.8%/y versus 17.0%/y, P=0.0006; sphincter dysfunction: 63.7%/y versus 11.3%/y, P=0.0002). According to the angiogram at the end of the latest treatment, 79% of type A and 75% of type B PVAVSs were completely obliterated. If the lesions were partially obliterated, a significantly higher clinical deterioration rate was observed in patients with type A shunts than those with type B shunts (69.9%/y versus 3.2%/y, P=0.0253). CONCLUSIONS Type A PVAVSs feature rapid progressive neurological deficits; therefore, early clinical intervention is necessary. For complex lesions that cannot be completely obliterated, surgical disconnection of all refluxed radicular veins is suggested.
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Affiliation(s)
- Yueshan Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Jiankun Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, China (L.B.)
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
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18
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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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Ryu B, Sato S, Takase M, Mochizuki T, Shima S, Inoue T, Okada Y, Niimi Y. Diagnostic accuracy of three-dimensional-rotational angiography and heavily T2-weighted volumetric magnetic resonance fusion imaging for the diagnosis of spinal arteriovenous shunts. J Neurointerv Surg 2021; 14:neurintsurg-2020-017252. [PMID: 33674393 PMCID: PMC8785054 DOI: 10.1136/neurintsurg-2020-017252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/10/2021] [Accepted: 02/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Spinal arteriovenous shunts (SAVSs) are rare entities occurring in various areas, from the craniocervical junction to the sacral level. Recently, better understanding of SAVS angioarchitecture and elucidation of its pathogenesis have become possible with the advancement of imaging techniques. However, the utility of fusing different image modalities for SAVS diagnostics has not been determined. This study aimed to investigate whether three-dimensional-rotational angiography (3D-RA) and 3D-heavily T2-weighted volumetric MR (3D-MR) fusion imaging would improve the diagnostic accuracy for SAVSs. METHODS We retrospectively reviewed 12 SAVSs in 12 patients. Assessment of 3D-RA and 3D-RA/3D-MR fusion images for SAVS was performed by seven blinded reviewers. The final diagnosis was performed by two interventional neuroradiologists with extensive experience, and the interobserver agreement between the reviewers and the final diagnosis was calculated using κ statistics. The comparison of the interobserver agreement between 3D-RA and 3D-RA/3D-MR fusion images was performed for the diagnosis of SAVS subtypes. We also statistically compared the image-quality gradings (on a 4-grade scale) to delineate the 3D relationship between vascular malformations and the surrounding anatomical landmarks. RESULTS The interobserver agreement for the 3D-RA/3D-MR fusion images was substantial (κ=0.7071) and higher than that for the 3D-RA images (κ=0.3534). Significantly better image quality grades were assigned to 3D-RA/3D-MR fusion images than to 3D-RA images (p<0.0001) for the evaluation of the examined 3D relationships. CONCLUSION The 3D-RA/3D-MR fusion images provided better interobserver agreement of SAVS subtype diagnosis, allowing for detailed evaluation of the SAVS anatomical structures surrounding the shunt.
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Affiliation(s)
- Bikei Ryu
- Neuroendovascular Therapy, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan .,Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan.,Neurosurgery, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Shinsuke Sato
- Neuroendovascular Therapy, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan.,Neurosurgery, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan.,Neurosurgery, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Masayuki Takase
- Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Tatsuki Mochizuki
- Neurosurgery, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Shogo Shima
- Neurosurgery, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Tatsuya Inoue
- Neurosurgery, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Yoshikazu Okada
- Neurosurgery, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Yasunari Niimi
- Neuroendovascular Therapy, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
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20
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Abstract
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.
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21
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Ohlsson M, Consoli A, DiMaria F, Sgreccia A, Rodesch G. Natural history and management of spinal cord arteriovenous shunts in pregnancy: A monocentric series of 10 consecutive cases with emphasis on endovascular treatment. J Neuroradiol 2020; 49:401-408. [PMID: 33007347 DOI: 10.1016/j.neurad.2020.09.006] [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: 05/19/2020] [Revised: 09/02/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Marcus Ohlsson
- Department of Neuroradiology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes France.
| | - Arturo Consoli
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes France
| | - Federico DiMaria
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes France
| | - Alessandro Sgreccia
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes France; Department of Radiology, Ospedali Riuniti, Ancona, Italy
| | - Georges Rodesch
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes France
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22
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Demin MO, Tekoev AR, Kushel YV. [Perimedullary arteriovenous fistula. Case report and literature review]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:76-81. [PMID: 32759930 DOI: 10.17116/neiro20208404176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Arteriovenous fistula is a common vascular abnormality of spinal cord and meninges. This disease is more common in young men. Clinical manifestation includes progressive sensitive and motor disorders. However, acute symptoms including impaired consciousness, head or back pain are also possible. The authors describe a rare case. A 15-year-old boy experienced acute depression of consciousness accompanied by headache, vomiting, weakness in the upper limbs and sensitive disorders. The patient was hospitalized to the intensive care unit and examined for subarachnoid hemorrhage. MRI of the head and cervical spine and direct invasive angiography were performed. Perimedullary AVF of cervical spinal cord was diagnosed. Complete clinical regression was observed within a month. Microsurgical removal of AVF was performed in scheduled fashion. Postoperative follow-up period was over 6 months.
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Affiliation(s)
- M O Demin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - A R Tekoev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - Yu V Kushel
- Burdenko Neurosurgical Center, Moscow, Russia
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23
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Niu X, Ren Y, Li J. Concomitant Sacral Dural Arteriovenous Fistula and Conus Medullaris Arteriovenous Malformation with Respective Drainage Veins: Case Report and Literature Review. World Neurosurg 2020; 141:299-305. [PMID: 32535050 DOI: 10.1016/j.wneu.2020.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Spinal dural arteriovenous fistulas (DAVFs) and spinal arteriovenous malformations (AVMs) are relatively rare. Moreover, multiple spinal cord vascular lesions in an individual, such as double DAVFs and DAVF with AVM, are extremely rare. To date, there are only several reported cases of concomitant spinal DAVFs and AVMs. CASE DESCRIPTION A 25-year-old woman presented with pain of the right lower limb persisting for 1 month. Spinal magnetic resonance imaging showed prominent signal flow voids in the lumbosacral canal. Spinal digital subtraction angiography (DSA) showed a sacral DAVF fed by the right lateral sacral artery and a spinal intradural AVM at the conus medullaris fed by the anterior spinal artery from the left T11 intercostal artery. The drainage veins in these 2 lesions were respective and without common anastomosis. The diagnosis of concomitant sacral DAVF and conus AVM was made. Microsurgery was performed to excise these lesions successfully in the same operation. The patient's symptoms gradually improved after surgery. Postoperative spinal DSA confirmed the complete disappearance of the 2 lesions. CONCLUSIONS The concomitant presence of sacral DAVF and conus AVM is extremely rare. Nonetheless, clinicians should be aware of the possibility of the coexistence of multiple types of spinal vascular lesions in a single patient.
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Affiliation(s)
- Xiaodong Niu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yanming Ren
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jin Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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Sechi E, Flanagan EP. Spinal arteriovenous fistula's often misdiagnosed as myelitis; can we stem the flow? J Neurol Sci 2020; 413:116868. [PMID: 32386907 DOI: 10.1016/j.jns.2020.116868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/24/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Elia Sechi
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Eoin P Flanagan
- Departments of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA; Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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25
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Clinical characteristics, misdiagnosis and outcomes of patients with low-flow spinal arteriovenous fistulas. J Neurol Sci 2020; 413:116863. [PMID: 32386730 DOI: 10.1016/j.jns.2020.116863] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/30/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To describe the clinical characteristics, delay to diagnosis and post-intervention outcomes of patients with low-flow spinal arteriovenous fistulas (SAVFs). METHODS In this retrospective observational study, we reviewed all patients with low-flow SAVFs angiographically diagnosed at our institution between 2008 and 2018. Pre- and post-intervention disability levels were recorded using the modified Aminoff and Logue scale (mALS). RESULTS One-hundred and five patients were included. Median age was 62 years and 79% were male. Most patients (56%) presented to neurologists and 41% were misdiagnosed with myelitis. Patients underwent unnecessary treatment with corticosteroids (44%), other immunosuppressive therapies (8%) and spinal surgery (10%). Inappropriate corticosteroid treatment led to a precipitous clinical decline in 30% of patients exposed. Only 21% percent of patients were correctly diagnosed after initial evaluation; the median delay to diagnosis in the rest of the cohort was of 12 months (IQR 7 to 24 months). Longer delays to diagnosis were associated with higher levels of disability (p = .002). Treatment of SAVF was endovascular in 64% and surgical in 26%; 13% of patients required further intervention due to incomplete initial treatment or fistula recurrence. Greater than 6 months after intervention, disability scores were improved in 52% and stable in 43% of patients. In individual patients, pre- and post-intervention disability scores were strongly correlated (p < .001). CONCLUSIONS Low-flow SAVFs are associated with substantial disability and are frequently misdiagnosed. Timely diagnosis of SAVF needs to improve, as endovascular or surgical treatment results in stabilization or improvement of disability in the vast majority of patients.
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