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Chen KS, Williams DD, Iacobas I, McClugage SG, Gadgil N, Kan P. Spontaneous thrombosis of high flow pediatric arteriovenous fistulae: Case series of two patients and a comprehensive literature review. Childs Nerv Syst 2024; 40:1405-1414. [PMID: 38085366 DOI: 10.1007/s00381-023-06241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/21/2023] [Indexed: 04/19/2024]
Abstract
Pediatric pial arteriovenous shunts in the brain and spine are challenging to understand because of low incidence, variable presentation, and associations with genetic syndromes. What is known about their natural history comes from reviews of small series. To better understand the natural history and role for intervention, two cases are presented followed by a review of the literature. In the first case, an infant with a prior history of intracranial hemorrhage from a ruptured pial fistula returns for elective embolization for a second pial fistula which was found to be spontaneously thrombosed 2 weeks later. In the second case, a 5-year-old with a vertebro-vertebral fistula, identified on work up for a heart murmur and documented with diagnostic angiography, is brought for elective embolization 6 weeks later where spontaneous thrombosis is identified. In reviewing the literature on pediatric single-hole fistulae of the brain and spine, the authors offer some morphologic considerations for identifying which high-flow fistulae may undergo spontaneous thrombosis to decrease the potentially unnecessary risk associated with interventions in small children.
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Affiliation(s)
- Karen S Chen
- Edward B. Singleton Department of Radiology and Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX, 77030, USA.
| | - Daniel Davila Williams
- Department of Neurology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 1250, Houston, TX, 77030, USA
| | - Ionela Iacobas
- Department of Pediatrics, Baylor College of Medicine, Vascular Anomalies Center at Texas Children's Cancer and Hematology Centers, Texas Children's Hospital, 6701 Fannin St, Suite 1510, Houston, TX, 77030, USA
| | - Samuel G McClugage
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 1230, Houston, TX, 77030, USA
| | - Nisha Gadgil
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 1230, Houston, TX, 77030, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, 1005 Harborside Dr, 5th floor, Galveston, TX, 77555, USA
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Isikbay M, Caton MT, Mattay R, Han W, Cooke DL, Raper D, Winkler EA, Savastano L, Narsinh KH, Hetts SW, Amans MR. Arteriovenous shunts of the cervical spine: patient demographics, presentation, patterns of high-risk venous drainage, and updated classification. J Neurointerv Surg 2024:jnis-2023-021353. [PMID: 38604766 DOI: 10.1136/jnis-2023-021353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/27/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Intracranial dural arteriovenous (AV) fistula classifications focus on presence/absence of retrograde flow in the cortical veins of the brain as this angiographic finding portends a worse prognosis. However, prior categorization systems of AV shunts in the spine do not incorporate these features. We propose an updated classification for spinal shunting lesions that terms any shunting lesion with retrograde flow in any cortical vein of the brain or spinal cord medullary vein as "high risk". To present this classification, we analyzed our center's most recent experience with cervical spine shunting lesions. METHODS The electronic medical record at our institution was reviewed to identify shunting lesions of the cervical spine and patient demographics/presentation. Comprehensive craniospinal digital subtraction angiograms were evaluated to classify shunt location, type (arteriovenous malformation (AVM) vs arteriovenous fistula (AVF)), and presence of high-risk venous drainage. RESULTS Some 52 lesions were identified and categorized as pial/dural/epidural/paravertebral AVFs and intramedullary/extraspinal AVMs. Lesions were classified as high risk or not depending on the presence of retrograde flow into at least one vein that directly drains the spinal cord or brain. All patients who presented with either hemorrhage or infarct had underlying high-risk lesions. Additionally, 50% (17/34) of symptomatic patients with high-risk lesions presented with neurological extremity symptoms (OR=10.0, p=0.037) most of which fit a myelopathic pattern. CONCLUSION We present an updated classification system for shunting lesions of the spine that focuses on high-risk retrograde flow to the brain or spine in addition to anatomical location in order to better inform patient management.
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Affiliation(s)
- Masis Isikbay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - M Travis Caton
- Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Raghav Mattay
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Woody Han
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel Raper
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Luis Savastano
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kazim H Narsinh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Reynolds CD, Caton MT, Baker A, Smith ER, Amans MR, Cooke DL, Dowd CF, Higashida RT, Gupta N, Abla AA, Auguste K, Fox CH, Fullerton H, Hetts SW. Clarifying the clinical landscape of pediatric spinal arteriovenous shunts: an institutional experience and individual patient-data meta-analysis. J Neurointerv Surg 2023; 16:94-100. [PMID: 36922033 DOI: 10.1136/jnis-2022-019797] [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: 11/16/2022] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Pediatric spinal arteriovenous shunts (SAVS) are rare lesions with heterogeneous pathogenesis and clinical manifestations. OBJECTIVE To evaluate the clinical characteristics, angioarchitecture, and technical/clinical outcomes in SAVS through a large single-center cohort analysis and meta-analysis of individual patient data. METHODS A retrospective institutional database identified children (aged 0-21 years) who underwent digital subtraction spinal angiography (DSA) for SAVS between January 1996 and July 2021. Clinical data were recorded to evaluate angioarchitecture, generate modified Aminoff-Logue gait disturbance scores (AL) and McCormick grades (MC), and assess outcomes. We then performed a systematic literature review following PRISMA-IPD (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for individual patient data) guidelines, extracting similar data on individual patients for meta-analysis. RESULTS The cohort consisted of 28 children (M:F=11:17) with 32 SAVS lesions, with a mean age of 12.8±1.1 years at diagnosis. At presentation, SAVS were most highly concentrated in the cervical region (40.6%). Children had a median AL=2 and MC=2, with thoracolumbar AVS carrying the greatest disability. Among treated cases, complete obliteration was achieved in 48% of cases and median AL scores and MC grades both improved by one point. Systematic literature review identified 161 children (M:F=96:65) with 166 SAVS lesions with a mean age of 8.7±0.4 years. Among studies describing symptom chronicity, 37/51 (72.5%) of children presented acutely. At presentation, children had a median AL=4 and MC=3, with thoracolumbar AVS carrying the highest MC grades. After intervention, median AL and MC both improved by one point. CONCLUSIONS This study provides epidemiologic information on the location, onset, and presentation of the full spectrum of pediatric SAVS, highlighting the role of targeted treatment of high-risk features.
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Affiliation(s)
- Conner D Reynolds
- Department of Medical Imaging, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - M Travis Caton
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Amanda Baker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Eric R Smith
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
| | - Matthew R Amans
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher F Dowd
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Randall T Higashida
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nalin Gupta
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Kurtis Auguste
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Christine H Fox
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather Fullerton
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
- Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
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Abruzzo T, van den Berg R, Vadivelu S, Hetts SW, Dishop M, Cornejo P, Narayanan V, Ramsey KE, Coopwood C, Medici-van den Herik EG, Roosendaal SD, Lawton M, Bernes S. Arterioectatic Spinal Angiopathy of Childhood: Clinical, Imaging, Laboratory, Histologic, and Genetic Description of a Novel CNS Vascular Pathology. AJNR Am J Neuroradiol 2022; 43:1060-1067. [PMID: 35772802 PMCID: PMC9262071 DOI: 10.3174/ajnr.a7551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/18/2022] [Indexed: 11/07/2022]
Abstract
Pediatric patients with myelopathy expressing intradural spinal vascular ectasia without arteriovenous shunting were studied at four tertiary referral neuropediatric centers. Patients were identified by retrospective review of institutional records and excluded if spinal vascular pathology could be classified into a previously described category of spinal vascular malformation. Four patients meeting the study criteria were enrolled in the study. Clinical, magnetic resonance imaging, catheter-directed angiography, laboratory, histological and genetic data were analyzed to characterize the disease process and elucidate underlying pathomechanisms. Our study revealed a highly lethal, progressive multi-segmental myelopathy associated with a unique form of non-inflammatory spinal angiopathy featuring diffuse enlargement and tortuosity of spinal cord arteries, spinal cord hyperemia, and spinal cord edema (Arterioectatic Spinal Angiopathy of Childhood). The condition was shown to mimic venous congestive myelopathy associated with pediatric spinal cord arteriovenous shunts on MRI but to have distinct pathognomonic findings on catheter-directed angiography. Clinicopathological, genetic, and neuroimaging features, which are described in detail, closely overlap with those of mitochondrial disease.
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Affiliation(s)
- T Abruzzo
- Department of Radiology (T.A., P.C., S.B.)
- Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
| | - R van den Berg
- Department of Radiology and Nuclear Medicine (R.v.d.B., S.D.R.), Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - S Vadivelu
- Department of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S W Hetts
- Department of Radiology (S.W.H.), University of California, San Francisco, San Francisco, California
| | - M Dishop
- Department of Pathology and Laboratory Medicine (M.D.)
- Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
| | - P Cornejo
- Department of Radiology (T.A., P.C., S.B.)
- Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
| | - V Narayanan
- Translational Genomics Research Institute (V.N., K.E.R.), Phoenix, Arizona
| | - K E Ramsey
- Translational Genomics Research Institute (V.N., K.E.R.), Phoenix, Arizona
| | - C Coopwood
- College of Medicine (C.C.), University of Arizona, Tucson, Arizona
| | | | - S D Roosendaal
- Department of Radiology and Nuclear Medicine (R.v.d.B., S.D.R.), Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - S Bernes
- Department of Radiology (T.A., P.C., S.B.)
- Department of Neurology (S.B.)
- Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
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Bankole N, Janot K, Listrat A, Travers N, Maldonado I, Velut S. Child pial arteriovenous fistula of the conus medullaris presenting with spinal cord venous congestion: Case report and literature review. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Pagiola I, Caroff J, Mihalea C, Aghakhani N, Ikka L, Chalumeau V, Iacobucci M, Ozanne A, Gallas S, Carrete H, Marques MC, Nalli D, Caldas JG, Frudit ME, Moret J, Parker F, Spelle L. Republished: Spinal arteriovenous malformation without endovascular arterial access: is a combined neurosurgical approach and direct venous puncture an option? J Neurointerv Surg 2020; 12:e4. [PMID: 32184273 DOI: 10.1136/neurintsurg-2019-015268.rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 11/03/2022]
Abstract
This case report describes a combined neurosurgical and endovascular approach for the treatment of a conus medullaris arteriovenous malformation resulting in considerable improvement in the patient's neurological condition (modified Rankin Scale score 2).
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Affiliation(s)
- Igor Pagiola
- NEURI, Hôpital Bicêtre, Le Kremlin-Bicêtre, France .,Neurorradiologia Intervencionista, UNIFESP, Escola Paulista de Medicina, São Paulo, Brazil
| | | | | | | | - Léon Ikka
- NEURI, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | | | | | - Henrique Carrete
- DDI, Universidade Federal de Sao Paulo Escola Paulista de Medicina, Sao Paulo, Brazil
| | - Marcio Chaves Marques
- Neurorradiologia Intervencionista, UNIFESP, Escola Paulista de Medicina, São Paulo, Brazil
| | - Darcio Nalli
- Neurorradiologia Intervencionista, UNIFESP, Escola Paulista de Medicina, São Paulo, Brazil
| | | | - Michel Eli Frudit
- Neurorradiologia Intervencionista, UNIFESP, Escola Paulista de Medicina, São Paulo, Brazil
| | | | - Fabrice Parker
- Neurosurgery, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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Rosi A, Consoli A, Condette-Auliac S, Coskun O, Di Maria F, Rodesch G. Concomitant conus medullaris arteriovenous shunts and sacral dural arteriovenous fistulas: pathophysiological links related to the venous drainage of the lesions in a series of five cases. J Neurointerv Surg 2018; 10:586-592. [DOI: 10.1136/neurintsurg-2017-013505] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 11/03/2022]
Abstract
BackgroundSpinal cord arteriovenous shunts (scAVSs) are a group of lesions located in the spinal cord itself or in the surrounding structures. The most common scAVSs are spinal dural arteriovenous fistulas (sDAVFs), which are acquired lesions. The pathogenesis of sDAVFs involves thrombosis and venous hypertension as trigger factors. Intradural scAVSs such as spinal cord arteriovenous nidus type malformations (AVMs) and pial arteriovenous fistulas are less common than sDAVFs and are considered to have a so-called ‘congenital’ origin. The association between different concomitant scAVSs is very rare and the association of sDAVFs with intradural scAVSs has been described in only a few case reports.MethodsWe describe a case series of five patients presenting with a conus medullaris AVS associated with a lower lumbar or sacral DAVF.ResultsThree of our patients were <30 years old at presentation. In four of these five cases the intradural scAVS drained caudally, engorging the epidural plexus in the same location as the sDAVF. In only one case, who presented with thrombosis of the drainage of the main compartment of a conus medullaris pial AVF, was the location of the DAVF opposite to the location of the residual drainage.ConclusionWe discuss the pathophysiological link between scAVS and sDAVF on the basis of the rarity of the DAVF, the uncommon association between scAVS and sDAVF, the presence of sDAVF in young patients, and the venous hypertension created by the venous drainage towards the sacral area responsible for angiogenesis creating the dural shunt.
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Giordan E, Brinjikji W, Ciceri E, Lanzino G. Arteriovenous fistulae of the filum terminale. J Neurointerv Surg 2017; 10:191-197. [DOI: 10.1136/neurintsurg-2017-013309] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/09/2017] [Accepted: 08/24/2017] [Indexed: 01/12/2023]
Abstract
Filum terminale arteriovenous fistulae are a rare type of arteriovenous shunt generally characterized by a single direct communication between the artery of the filum terminale and a single draining vein. These intradural arteriovenous shunts are three times more common in men than women (mean age 55 years). Symptoms are related to venous congestion, vascular hypertension, and a putative chronic steal phenomenon which result in spinal cord ischemia and myelopathy. Interestingly, hemorrhage has never been reported as a mode of presentation. MRI demonstrates increased flow voids and T2 changes involving the conus and the lower spinal cord, and these findings are not dissimilar from those seen with the more common type 1 spinal dural arteriovenous fistulae. Thus conventional spinal angiography is necessary for a definitive diagnosis and to localize exactly the site of the fistula. Both surgical interruption of the fistula and endovascular embolization are safe and effective therapeutic modalities. However, because of the very small caliber of the feeding artery, endovascular therapy is often not feasible; and thus, surgery remains the method more commonly utilized for their treatment. Definitive treatment consists of obliteration of the direct arteriovenous shunt. In this review, we describe the anatomy, pathophysiology, clinical presentation, imaging, and treatment options of these less common intradural arteriovenous shunts.
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Onda K, Yoshida Y, Watanabe K, Arai H, Okada H, Terada T. High cervical arteriovenous fistulas fed by dural and spinal arteries and draining into a single medullary vein: report of 3 cases. J Neurosurg Spine 2014; 20:256-64. [PMID: 24438426 DOI: 10.3171/2013.11.spine13402] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECT The authors previously reported a case of complex arteriovenous fistula (AVF) at C-1 with multiple dural and spinal feeders that were linked with a common medullary venous channel. The purpose of the present study was to collect similar cases and analyze their angioarchitecture to gain a better understanding of this malformation. METHODS Three such cases, affecting 2 males and 1 female in their 60s who had presented with hematomyelia (2) or progressive myelopathy (1), were treated surgically, and the operative findings from all 3 cases were compared using digital subtraction angiography (DSA) to determine the angioarchitecture. RESULTS The C-1 and C-2 radicular arteries and anterior and posterior spinal arteries supplied feeders to a single medullary draining vein in various combinations and via various routes. The drainage veins ran along the affected ventral nerve roots and lay ventral to the spinal cord. The sites of shunting to the vein were multiple: dural, along the ventral nerve root in the subarachnoid space, and on the spinal cord, showing a vascular structure typical of dural AVF, that is, a direct arteriovenous shunt near the spinal root sleeve fed by one or more dural arteries and ending in a single draining vein, except for intradural shunts fed by feeders from the spinal arteries. In 2 cases with hemorrhagic onset the drainer flowed rostrally, and in 1 case associated with congestive myelopathy the drainer flowed both rostrally and caudally. Preoperative determination of the shunt sites and feeding arteries was difficult because of complex recruitment of the feeders and multiple shunt sites. The angioarchitecture in these cases was clarified postoperatively by meticulous comparison of the DSA images and operative video. Direct surgical intervention led to a favorable outcome in all 3 cases. CONCLUSIONS A high cervical complex AVF has unique angioarchitectural characteristics different from those seen in the other spinal regions.
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Affiliation(s)
- Kiyoshi Onda
- Department of Neurosurgery, Niigata Neurosurgical Hospital, Yamada, Niigata; and
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Cohen JE, Constantini S, Gomori JM, Benifla M, Itshayek E. Pediatric perimedullary arteriovenous fistula of the conus medullaris supplied by the artery of Desproges-Gotteron. J Neurosurg Pediatr 2013; 11:426-30. [PMID: 23350679 DOI: 10.3171/2012.12.peds12363] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The cone artery, or artery of Desproges-Gotteron, is sometimes seen arising from the internal iliac artery. The authors describe a case of a symptomatic perimedullary arteriovenous fistula (AVF) of the conus medullaris in an 8-year-old boy who presented with a protracted history of urinary difficulty and severe sudden-onset right lumbosciatic pain that evolved to severe paraparesis with compromise of the sphincter muscles. The spinal AVF, which was supplied by the cone artery and a thoracic radiculomedullary artery that joined at the fistula site in a large partially thrombosed varix, was completely occluded with Onyx liquid embolic. The patient's clinical condition improved rapidly after embolization. As shown in this patient, urgent endovascular embolization of spinal AVFs can be very rewarding, even in patients with severe neurological presentation. The artery of Desproges-Gotteron appears to be a rare arterial variation. To the authors' knowledge, this is the first pediatric case of a conal AVF supplied by this artery.
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Affiliation(s)
- José E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.
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Choi IS. Spinal arteriovenous metameric syndrome: angioarchitecture and their prognosis. AJNR Am J Neuroradiol 2013; 34:464-5. [PMID: 22936097 DOI: 10.3174/ajnr.a3318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- I S Choi
- Lahey Clinic Medical CenterTufts University School of Medicine, Burlington, Massachusetts, USA
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SGUBIN D, KANAI R, DI PAOLA F, PERIN A, LONGATTI P. Conus Medullaris-Cauda Arteriovenous Malformation and Klippel-Trenaunay Syndrome: What is the Treatment Goal? Neurol Med Chir (Tokyo) 2013; 53:110-4. [DOI: 10.2176/nmc.53.110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Alessandro PERIN
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico “C. Besta”
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Sato K, Endo T, Niizuma K, Fujimura M, Inoue T, Shimizu H, Tominaga T. Concurrent dural and perimedullary arteriovenous fistulas at the craniocervical junction: case series with special reference to angioarchitecture. J Neurosurg 2012; 118:451-9. [PMID: 23176338 DOI: 10.3171/2012.10.jns121028] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Dural arteriovenous fistulas (DAVFs) and perimedullary arteriovenous fistulas (PAVFs) are uncommonly associated in the craniocervical junction. The purpose of this study was to describe the clinical and angiographic characteristics of such concurrent lesions. METHODS Authors reviewed 9 cases with a coexistent DAVF and PAVF at the craniocervical junction. Clinical presentation, angiographic characteristics, intraoperative findings, and treatment outcomes were assessed. RESULTS All patients (male/female ratio 5:4; mean age 66.3 years) presented with subarachnoid hemorrhage. Angiography revealed that 8 patients had both a DAVF and PAVF on the same side, whereas 1 patient had 3 arteriovenous fistulas, 1 DAVF, and 1 PAVF on the right side and 1 DAVF on the left side. All of the fistulas shared dilated perimedullary veins (anterior spinal vein, 7 cases; anterolateral spinal vein, 2 cases) as a main drainage route. The shared drainage route was rostrally directed in 8 of 9 cases. Eight patients exhibited an arterial aneurysm on the distal side of the feeding arteries to the PAVF, and the aneurysm in each case was intraoperatively confirmed as a bleeding point. One patient had ruptured venous ectasia at the perimedullary fistulous point. All patients underwent direct surgery via a posterolateral approach. No recurrence was observed in the 4 patients who underwent postoperative angiography, and no rebleeding event was recorded among any of the 9 patients during the follow-up period (mean 38.4 months). CONCLUSIONS The similarity of the angioarchitecture and the close anatomical relationship between DAVF and PAVF at the craniocervical junction suggested that these lesions are pathogenetically linked. The pathophysiological mechanism and anatomical features of these lesions represent a unique vascular anomaly that should be recognized angiographically to plan a therapeutic strategy.
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Affiliation(s)
- Kenichi Sato
- Department of Neuroendovascular Therapy, Tohoku University Graduate School ofMedicine, Sendai, Japan.
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Linfante I, Tari Capone F, Dabus G, Gonzalez-Arias S, Lau PE, Samaniego EA. Spinal arteriovenous malformation associated with spinal metameric syndrome: a treatable cause of long-term paraplegia? J Neurosurg Spine 2012; 16:408-13. [PMID: 22225485 DOI: 10.3171/2011.12.spine11636] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cutaneomeningospinal angiomatosis, or Cobb syndrome, is a rare metameric developmental disorder presenting as an extradural-intradural vascular malformation that involves bone, muscle, skin, spinal cord, and nerve roots. A 14-year-old girl with a red nevus involving the T6-9 dermatomes on the left side of her back presented with a 5-year history of bowel and bladder incontinence, paraplegia, and lower-extremity sensory loss. Magnetic resonance imaging demonstrated a hemangioma in the T-8 and T-9 vertebral bodies and a spinal cord AVM nidus extending from T-6 to T-9. The AVM was successfully embolized and the patient regained lower-extremity strength, ambulation, and normal sphincter functions after 5 years of having been wheelchair bound. The authors report the restoration of ambulation after endovascular embolization of a large spinal AVM in a patient with long-standing paraplegia due to Cobb syndrome.
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Affiliation(s)
- Italo Linfante
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA.
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Lim SM, Choi IS, David CA. Spinal arteriovenous fistulas of the filum terminale. AJNR Am J Neuroradiol 2011; 32:1846-50. [PMID: 21852379 DOI: 10.3174/ajnr.a2612] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The filum terminale is an anatomic structure at the end of the spinal cord. Only a few cases of AVFs of the filum terminale have been reported. These AVFs usually consist of a single communication between the anterior spinal artery and a single draining vein. We retrospectively analyzed the clinical and radiologic features and treatment of 4 patients with spinal AVFs of the filum terminale. Clinical manifestations and MR images are similar to those of spinal dural AVFs. All patients underwent surgical or endovascular treatment, resulting in complete occlusion. Clinical outcomes were good to excellent in all patients.
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Affiliation(s)
- S M Lim
- Department of Radiology, Ewha Womans University Hospital, Seoul, Korea
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Alomari AI, Orbach DB, Mulliken JB, Bisdorff A, Fishman SJ, Norbash A, Alokaili R, Lord DJ, Burrows PE. Klippel-Trenaunay syndrome and spinal arteriovenous malformations: an erroneous association. AJNR Am J Neuroradiol 2010; 31:1608-12. [PMID: 20651014 DOI: 10.3174/ajnr.a2167] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE KTS is a rare limb overgrowth disorder with slow-flow vascular anomalies. This study examines the presumed association between KTS and spinal AVMs. MATERIALS AND METHODS We performed a MEDLINE search of articles and reviewed textbooks of spinal diseases to study the association between KTS and spinal AVM. Our goal was to ascertain the basis on which the diagnosis of KTS was established and to evaluate the evidence of its association with spinal AVMs. In addition, the data base of the Vascular Anomalies Center at Children's Hospital Boston was queried for patients with KTS, and the association with spinal AVM was investigated. RESULTS Twenty-four published reports on spinal AVMs in 31 patients with KTS were reviewed. None of these references provided solid evidence of the diagnosis of KTS in any patient. Clinical data were either incompatible with the diagnosis of KTS or were inadequate to establish the diagnosis. Alternative possible diagnoses (CLOVES syndrome and CM-AVM) were suggested by the first author for 9 of the patients reported in these articles. The medical records of 208 patients with the diagnosis of KTS were analyzed; not a single patient had clinical or radiologic evidence of a spinal AVM. CONCLUSIONS An association between KTS and spinal AVM, as posited in numerous references, is most likely erroneous. The association has neither been reliably proved in the limited published literature nor encountered in a large cohort.
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Affiliation(s)
- A I Alomari
- Division of Interventional Radiology,Children’s Hospital Boston, 300 Longwood Ave., Boston, MA 02115, USA.
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Kim DJ, Willinsky R, Geibprasert S, Krings T, Wallace C, Gentili F, Terbrugge K. Angiographic characteristics and treatment of cervical spinal dural arteriovenous shunts. AJNR Am J Neuroradiol 2010; 31:1512-5. [PMID: 20413606 DOI: 10.3174/ajnr.a2109] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Spinal DAVSs of the cervical level are rare lesions. The purpose of this study is to describe the clinical and angiographic characteristics of cervical spinal DAVSs. From a prospectively collected database including 449 cases of brain and spinal DAVSs, lesions located at the cervical level were selected. The clinical presentation, angiographic characteristics, and treatment outcome were assessed. Twelve cases of spinal DAVSs were identified at the level of the cervical spinal canal (male to female ratio = 8:4; mean age = 56.5 years). Five patients (41.7%) presented with hemorrhage including SAH (n = 4) and cerebellar hemorrhage (n = 1). Coincidental spinal DAVSs with cranial DAVSs or brain AVMs were noted in 5 cases (41.7%). The spinal DAVS was the symptomatic lesion in 10 cases and was incidentally discovered during evaluation for SAH from a coincidental lesion in 2 cases. Combined endovascular and surgical resection resulted in symptomatic improvement in 10 patients. In conclusion, DAVSs of the cervical spine are rare lesions which often present with hemorrhage and are frequently associated with complex coincidental vascular lesions. Combined endovascular and surgical treatment will result in good outcome.
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Affiliation(s)
- D J Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea.
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Kenning TJ, Deshaies EM, Adamo MA, Waldman JB, Boulos AS. Onyx embolization of a thoracolumbar perimedullary spinal arteriovenous fistula in an infant presenting with subarachnoid and intraventricular hemorrhage. J Neurosurg Pediatr 2009; 3:211-4. [PMID: 19338467 DOI: 10.3171/2008.12.peds0870] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Identifying a source of spontaneous subarachnoid hemorrhage (SAH) or intraventricular hemorrhage (IVH) in patients with negative results on cranial angiographic imaging can be a diagnostic challenge. The authors present the case of a 14-month-old girl who presented with lethargy and spontaneous SAH and IVH, and later became acutely paraplegic. Except for the SAH and IVH, findings on neuroimages of the brain were normal. Magnetic resonance imaging revealed an intramedullary thoracolumbar spinal cord hemorrhage that was found to be associated with arterialized veins intraoperatively. Catheter-based diagnostic angiography identified a spinal perimedullary macroarteriovenous fistula (macro-AVF) that was completely embolized with Onyx, negating the need for further surgical intervention. The authors believe this to be the first reported case of a thoracolumbar perimedullary macro-AVF presenting with SAH and IVH. In addition, descriptions of Onyx embolization of a spinal AVF in the literature are rare, especially in pediatric patients.
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Affiliation(s)
- Tyler J Kenning
- Division of Neurosurgery, Department of Surgery, Albany Medical Center, Albany, New York 12208, USA.
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Abstract
Spinal dural arteriovenous (AV) fistulas are the most commonly encountered vascular malformation of the spinal cord and a treatable cause for progressive para- or tetraplegia. They most commonly affect elderly men and are classically found in the thoracolumbar region. The AV shunt is located inside the dura mater close to the spinal nerve root where the arterial blood from a radiculomeningeal artery enters a radicular vein. The increase in spinal venous pressure leads to decreased drainage of normal spinal veins, venous congestion, and the clinical findings of progressive myelopathy. On MR imaging, the combination of cord edema, perimedullary dilated vessels, and cord enhancement is characteristic. Therapy has to be aimed at occluding the shunting zone, either by superselective embolization with a liquid embolic agent or by a neurosurgical approach. Following occlusion of the fistula, the progression of the disease can be stopped and improvement of symptoms is typically observed.
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Affiliation(s)
- T Krings
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital and Hospital for Sick Children, Toronto, Ontario, Canada.
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Carette MF, Nedelcu C, Tassart M, Grange JD, Wislez M, Khalil A. Imaging of hereditary hemorrhagic telangiectasia. Cardiovasc Intervent Radiol 2008; 32:745-57. [PMID: 18972161 PMCID: PMC2705726 DOI: 10.1007/s00270-008-9344-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 02/25/2008] [Accepted: 03/03/2008] [Indexed: 11/27/2022]
Abstract
This pictorial review is based on our experience of the follow-up of 120 patients at our multidisciplinary center for hereditary hemorrhagic telangiectasia (HHT). Rendu-Osler-Weber disease or HHT is a multiorgan autosomal dominant disorder with high penetrance, characterized by epistaxis, mucocutaneous telangiectasis, and visceral arteriovenous malformations (AVMs). The research on gene mutations is fundamental and family screening by clinical examination, chest X-ray, research of pulmonary shunting, and abdominal color Doppler sonography is absolutely necessary. The angioarchitecture of pulmonary AVMs can be studied by unenhanced multidetector computed tomography; however, all other explorations of liver, digestive bowels, or brain require administration of contrast media. Magnetic resonance angiography is helpful for central nervous system screening, in particular for the spinal cord, but also for pulmonary, hepatic, and pelvic AVMs. Knowledge of the multiorgan involvement of HHT, mechanism of complications, and radiologic findings is fundamental for the correct management of these patients.
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Affiliation(s)
- Marie-France Carette
- Radiology Department, AP-HP Tenon Hospital, 4 Rue de la Chine, 75020, Paris, France.
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Abstract
In this historical perspective, the author identifies three epochs in the development of the concepts and treatment of spinal vascular lesions: 1) early observations (1860s-1912), with the lesions during this time period recognized only at autopsy; 2) the "middle ages" (1912-1960), with surgical intervention sporadic and yielding dismal results; and 3) the modern era (beginning in the 1960s), coincident with parallel dramatic advances in radiology, microsurgical instrumentation, and anesthesiology. These advances resulted in a better understanding of the pathophysiological aspects and angioarchitecture of the lesions. Whereas the nomenclature of the lesions in the past was confusing, a new understanding of these diseases that has emerged during the modern era has permitted refinement of the classification of the lesions as distinct biological entities. Modern diagnostic imaging has enabled identification of patients who may benefit from surgical or embolic occlusion, and treatment has become rationally based. Future progress in the management of spinal vascular lesions may be anticipated, with improvement in noninvasive imaging for early detection of suspected abnormalities. Furthermore, advances in spinal cord neuroprotection may expand the range of future options for surgical or embolic intervention.
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Zozulya YP, Slin'ko EI, Al-Qashqish II. Spinal arteriovenous malformations: new classification and surgical treatment. Neurosurg Focus 2006; 20:E7. [PMID: 16711664 DOI: 10.3171/foc.2006.20.5.8] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Object
Spinal vascular malformations represent rare and insufficiently studied pathological entities characterized by considerable variation. Insufficient study of this disease is connected with the complexity of its diagnosis, which restricts the development of surgical treatments that are differentiated according to the type of malformation. Great difficulties are caused by the lack of a clear structural–hemodynamic classification of spinal arteriovenous malformations (AVMs). At present the classification created between 1991 and 1998 by the combined efforts of different authors is the most widely used one. According to this classification, four categories are distinguishable: Type I, dural arteriovenous fistulas (AVFs); Type II, intramedullary glomus AVMs; Type III, juvenile or combined AVMs; and Type IV, intradural perimedullary AVFs. Vascular tumors are also classified, as follows: hemangiomas, hemangioblastomas, angiosarcomas, hemangiopericytomas, angiofibromas, angiolipomas, and hemangioendotheliomas, as well as cavernous malformations.
Methods
In this study the authors analyze the diagnostic data and results of treatment in 91 patients with AVMs and AVFs who were treated at the Institute of Neurosurgery between 1995 and 2005. The patients' ages ranged from 9 to 83 years; the mean age was 42.9 years. For spinal vascular malformations we devised a classification that took into account the aforementioned features of AVMs: the anatomical characteristics of a malformation and its angiostructural and hemodynamic features. In all patients the neuroimaging modalities used in the investigation of their lesions included magnetic resonance (MR) imaging and selective spinal angiography. Three-dimensional computerized tomography angiography studies were obtained in 14 patients, and MR angiography was used in 17.
Conclusions
For successful surgical treatment of spinal AVMs it is necessary to obtain data about their localization, vascular structure, and hemodynamics that are as complete as possible. This information will promote the use of optimum surgical procedures and the latest methods of microsurgical and endovascular interventions, with treatments differentiated according to the type of malformation. One should try to use the least invasive endovascular approach in these cases,where possible, to occlude the AVM or reduce the intensity of blood flow by means of embolization. To perform an AVM resection or occlusion, one should use a direct approach to the malformation, blocking only the vessels supplying blood to the malformation and preserving the vessels feeding the spinal cord.
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