Myelopathy from intracranial dural arteriovenous fistula

Watch brain circulation in unexplained progressive myelopathy: a review of Cognard type V arterio-venous fistulas

BACKGROUND

Intracranial dural arterio-venous fistulas are pathological anastomoses between arteries and veins located within dural sheets and whose clinical manifestations depend on location and hemodynamic features. They can sometimes display perimedullary venous drainage (Cognard type V fistulas-CVFs) and present as a progressive myelopathy. Our review aims at describing CVFs' variety of clinical presentation, investigating a possible association between diagnostic delay and outcome and assessing whether there is a correlation between clinical and/or radiological signs and clinical outcomes.

METHODS

We conducted a systematic search on Pubmed, looking for articles describing patients with CVFs complicated with myelopathy.

RESULTS

A total of 72 articles for an overall of 100 patients were selected. The mean age was 56.20 ± 14.07, 72% of patients were man, and 58% received an initial misdiagnosis. CVFs showed a progressive onset in 65% of cases, beginning with motor symptoms in 79% of cases. As for the MRI, 81% presented spinal flow voids. The median time from symptoms' onset to diagnosis was 5 months with longer delays for patients experiencing worse outcomes. Finally, 67.1% of patients showed poor outcomes while the remaining 32.9% obtained a partial-to-full recovery.

CONCLUSIONS

We confirmed CVFs' broad clinical spectrum of presentation and found that the outcome is not associated with the severity of the clinical picture at onset, but it has a negative correlation with the length of diagnostic delay. We furthermore underlined the importance of cervico-dorsal perimedullary T1/T2 flow voids as a reliable MRI parameter to orient the diagnosis and distinguish CVFs from most of their mimics.

Case report: A choroidal fissure pial arteriovenous malformation inducing venous congestive edema of the medulla oblongata and cervicothoracic spinal cord presented with proximal arm predominant weakness

Intracranial dural arteriovenous fistula (DAVF) can induce remote myelopathy via spinal perimedullary venous drainage. In the present study, we report a rare case of intracranial pial arteriovenous malformation (AVM)-related myelopathy. A 52-year-old man presented with progressive, predominantly proximal weakness and muscle atrophy in bilateral upper limbs, urinary retention, and hyperreflexia in bilateral upper and lower limbs. Brain and cervicothoracic MRI showed longitudinal myelopathy extending from the medulla oblongata to the T6 level, with perimedullary enlarged veins from the C1 to T12 level, and remarkable enhancement in bilateral anterior horns from the C2 to C7 level. Cerebral angiography revealed a choroidal fissure AVM, which was supplied by the left anterior choroidal artery and drained exclusively by an inferior ventricular vein descending toward the spinal perimedullary veins. After endovascular embolization of the feeding pedicle, nidus, and proximal segment of the draining vein, the patient's neurological deficits rapidly improved, and a significant recovery was achieved 3 months after the procedure. This rare case indicates that intracranial pial AVM can also cause extensive congestive myelopathy with similar mechanisms underlying intracranial and craniocervical DAVF cases, and gray matter in the spinal cord might be more susceptible to ischemia induced by intraspinal venous hypertension.

Tentorial dural arteriovenous fistula with perimedullary venous drainage-associated cervical myelopathy: illustrative case

BACKGROUND

Tentorial dural arteriovenous fistulas (DAVFs) with perimedullary venous drainage causing cervical myelopathy are very uncommon conditions with an extremely aggressive behavior. When the characteristic radiological clues are missing, the unspecific clinical picture may cause delay and make the diagnosis challenging.

OBSERVATIONS

Here the authors report a case of a 58-year-old man who developed progressive spastic tetraparesis and dyspnea with an extensive mild enhancing cervical cord lesion initially oriented as a neurosyphilis-associated transverse myelitis. Acute worsening after steroid administration redirected the diagnosis, and a tentorial Cognard type V DAVF was elicited. The microsurgical disconnection process is described, and previously documented cases in the literature are reviewed.

LESSONS

If a DAVF is highly suspected, it is important to consider the possibility of its intracranial origin, and spinal as well as cerebral arteriography must be performed.

Vascular Myelopathies

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Intracranial Dural Arteriovenous Fistulas With Brainstem Engorgement: An Under-Recognized Entity in Diagnosis and Treatment

Background: In rare circumstances, patients with intracranial (dural arteriovenous fistulas) DAVFs could be complicated with brainstem engorgement, which might lead to delayed or false diagnosis and subsequent improper management.

Methods: On July 2th, 2019, a systematic search was conducted in the PubMed database for patients with intracranial DAVFs complicated with brainstem engorgement.

Results: Sixty-eight articles reporting of 86 patients were included for final analysis. The patients were aged from 20 to 76 years (57.10 ± 12.90, n = 82). The female to male ratio was 0.68 (35:51). Thirty-three (40.2%, 33/82) patients were initially misdiagnosed as other diseases. The specific location distributions were cranio-cervical junction, cavernous sinus, superior petrosal sinus, transverse and/or sigmoid sinus, tentorium, and other sites in 27 (32.5%), 11 (13.2%), 9 (10.8%), 10 (12.0%), 21 (25.3%), and 5 (6.0%) patients, respectively. The Cognard classification of DAVFs were II, III, IV, and V in 9 (10.7%, 9/84), 1 (1.2%, 1/84), 1 (1.2%, 1/84), and 73 (86.9%, 73/84) patients. Eighteen (22%, 18/82) patients were demonstrated to have stenosis or occlusion of the draining system distal to the fistula points. The mean follow-up period was 7.86 (n = 74, range 0–60 months) months. Fifty-four (70.1%, 54/77) patients experienced a good recovery according to the mRS score.

Conclusions: Intracranial DAVFs complicated with brainstem engorgement are rare entities. Initial misdiagnosis and delayed definite diagnosis are common in the past three decades. The treatment outcome is still unsatisfactory at present. Early awareness of this rare entity and efficiently utilizing the up to date investigations are of utmost importance.

Long-standing tentorial dural arteriovenous fistula presenting as progressively worsening cervical myelopathy by degenerative cervical intervertebral disc: a case report

We report a rare case of long-standing asymptomatic tentorial dural arteriovenous fistula (DAVF) presenting as symptomatic progressive cervical myelopathy which was caused by the protrusion of degenerative cervical intervertebral discs into the spinal canal and compression of the anterior spinal vein. The cervical spinal canal was narrowed, and the spinal cord was compressed anteriorly by protrusion of cervical intervertebral discs at the C6-7 level. The intervertebral discs compressed the draining vein of the tentorial DAVF (the anterior spinal vein) so venous congestion of the spinal cord resulted in cervical myelopathy only above the C6 level.

Myelopathy Due to Intracranial Dural Arteriovenous Fistula with Perimedullary Venous Drainage: Clinical and Medicolegal Aspects in a Case of Diagnostic Pitfall

BACKGROUND

Intracranial dural arteriovenous fistula (DAVF) consists of a meshwork of arteriovenous shunts. Drainage of the fistula may be into a dural sinus or directly into cortical veins. Rarely, dural arteriovenous fistulas drain exclusively into perimedullary veins. Prompt diagnosis is important, as the clinical course is potentially life threatening.

CASE DESCRIPTION

A 67-year-old man presented with difficulties in walking and bladder retention. Magnetic resonance imaging showed central myelopathy, edema from C6 to T8, and dilated posterior medullary veins. Spinal angiography showed no abnormalities. The diagnostic impression was one of inflammatory demyelinating disease, and the patient was treated with corticosteroids. Three days later, the patient had become paraparetic. Brain magnetic resonance imaging showed abnormal vascular structures around the lower brainstem and cervical cord. Cerebral angiography showed a dural fistula at the skull base supplied by the neuromeningeal branch of the ascending pharyngeal artery and draining into the posterior medullary veins. Following neurosurgical referral, the draining vein was clipped just beyond the arterial feeders. At that time, the patient was wheelchair-bound and needed assistance in daily activities.

CONCLUSIONS

Early diagnosis of this rare vascular malformation is challenging; angiographic studies must include the cranial vasculature when spinal studies are normal or if the abnormality on magnetic resonance imaging is maximal in the upper spinal cord. In the case described, as only medullary angiography was performed, the intracranial dural arteriovenous fistula with perimedullary venous drainage was not diagnosed. Delayed diagnosis is likely to lead to severe neurologic consequences.

Factors influencing the prognosis in intracranial dural arteriovenous fistulas with perimedullary drainage

OBJECTIVE

Intracranial dural arteriovenous fistulas with perimedullary venous drainage (IDAVFPD) are classified as type V dural arteriovenous fistulas. Publications are limited to single case reports and small case series. We conducted a systematic review of the literature for patients with IDAVFPD. The aim of this study is to identify the predictive factors of poor prognosis in patients with IDAVFPD.

METHODS

We present the case of a 48-year-old man who underwent surgical interruption of IDAVFPD. A complete MEDLINE search was then undertaken for all articles reporting outcomes data for IDAVFPD. According to the results we have divided the patient population into two groups: I, those patients who showed improvement after treatment, and II: those patients who did not show improvement. We conducted a comparative statistical analysis of the epidemiologic, clinical, radiologic, and therapeutic parameters between the two groups.

RESULTS

A total of 37 articles comprising with 58 cases were included for analysis with an average follow-up of 12 months. There were 36 patients in group I and 22 in group II. The average age was 57.8 years in group I and 54.3 years in group II (P=0.32). Onset of symptoms was acute or subacute in 57% of patients in group I, and in 50% of patients in group II (P=0.62). Bulbar signs were present in 28% of cases in group I and in 36% of cases in group II (P=0.49). Hyperintensity of the brainstem on T2-weighted sequence magnetic resonance imaging was more common in patients in group II (78%) compared with patients in group I (45%) (P=0.012). Patients who underwent surgical procedure have shown good outcomes compared to patients treated with endovascular approach (P=0.039).

CONCLUSIONS

The poor outcomes were correlated to the presence of brainstem signal abnormalities on magnetic resonance imaging, whereas the prognosis does not depend on age, sex, clinical presentation, or anatomic characteristics of the fistula.

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSIONS

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

Les myélopathies secondaires aux fistules durales artério-veineuses peuvent-elles être aggravées par la corticothérapie intraveineuse ?

Dural fistulas are the most common vascular malformations of the spinal cord. They are of unknown origin but constitute a recognized cause of myelopathy. Aggravation of the clinical manifestations, either spontaneously or after invasive procedures, has been described. We report the case of a patient with a four-month history of myelopathic syndrome involving the lower limbs. Intravenous corticosteroid steroid treatment (1g) given for a suspected inflammatory disorder, induced a dramatic flare-up of the neurological symptoms which were reversible within 48 hours after corticosteroid withdrawal. The causal effect of the steroid treatment is discussed.

The role of non-invasive computed tomography in patients with suspected dural fistulas with spinal drainage

OBJECTIVE

Accurate diagnosis and demonstration of the angioarchitecture and localization of a spinal dural arteriovenous fistula is of crucial importance before treatment. Selective spinal angiography (DSA) has been considered the standard technique, but is invasive, time-consuming, and may be falsely negative. This report evaluates the use of noninvasive vascular imaging (computed tomographic and magnetic resonance angiography [MRA]) in patients suspected to have a dural fistula with spinal drainage.

METHOD

Ten consecutive patients had DSA and multidetector computed tomographic angiography (MDCTA), eight also had MRA. Nine were men with an average age of 67 years. In nine patients, the diagnosis was confirmed at surgery or intravascular treatment. Eight were proven to have a spinal dural fistula. In two, the fistula was within the cervical cranial dura. In all patients, the venous drainage involved only the spinal venous plexus.

RESULTS

MDCTA identified the level of the feeding artery in nine patients. In two cases, selective DSA failed to show the abnormality found on MDCTA, but both were confirmed at surgery. MRA was diagnostic in a case in which the lesion was not accurately depicted by either MDCTA or DSA. MRA was less accurate than MDCTA in determining the level of the feeding artery.

CONCLUSION

MDCTA and MRA can direct and focus DSA. MDCTA gives additional useful three-dimensional bone detail and localization information for the surgeon. It may replace DSA if surgery is the planned treatment.

Brain stem ischemia from intracranial dural arteriovenous fistula: Case report

BACKGROUND

Intracranial dural arteriovenous fistulas (AVFs) with spinal perimedullary venous drainage are rarely reported, but most of the patients initially have presented with myelopathy or subarachnoid hemorrhage. This is the first report of the intracranial dural AVF patient who presented with brain stem infarction.

CASE DESCRIPTION

A 38-year-old woman experienced nausea and vomiting with an acute onset, followed by vertigo. Magnetic resonance imaging showed ischemic lesion in the medulla oblongata, and she was then sent to our hospital. On admission, she had nystagmus, swallowing difficulties, Homer syndrome, and right hemiparesis and hemisensory disturbance. Cerebral angiography revealed dural AVF draining into spinal perimedullary veins at the left transverse-sigmoid sinus. The patient was treated by transvenous embolization under local anesthesia. A microcatheter proceeded to the left sigmoid sinus via the internal jugular vein, and embolization of the sinus was performed using coils without complications. The patient's swallowing difficulties improved over a few days after the embolization, and one month later, there remained only a slight mild hemiparesis and hemisensory disturbance. Six months after the onset, there was no ischemic lesion in the brain stem on magnetic resonance imaging.

CONCLUSIONS

In this case, we showed the possibility of brain stem infarction, caused by the intracranial dural AVF.

Tétraplégie brutale C3-C4 révélant une fistule durale artérioveineuse intracrânienne à drainage veineux périmédullaire

We report a case of intracranial dural arteriovenous (DAVF) draining into the spinal medullary veins. A 49-year-old woman presented a rapidly progressive ascending myelopathy resulting in a C3-C4 tetraplegia associated with acute respiratory failure at the twelfth hour. MRI revealed swelling of the cervical spinal cord, hyperintensity on T2 and enhancement of enlarged veins on MR angiography. A conventional angiography showed the DAVF with venous drainage into the spinal vein extending to the conus medullaris. After embolization, neurological recovery occurred during the first week, allowing tracheal extubation on day 2. Clinical, radiological and therapeutic aspects of this uncommon pathology are presented.

Venous congestive myelopathy: a mimic of neoplasia

Venous congestive myelopathy is a progressive disorder frequently associated with arteriovenous fistulas, usually dural. By causing diffuse spinal cord enlargement and enhancement on imaging, it may simulate a neoplasm and prompt a biopsy. We evaluated the biopsy findings in seven such patients (M=5, F=2, mean age 59+/-11 years) who presented variably with progressive lower extremity weakness (86%), bowel and bladder dysfunction (86%), sensory changes (86%) or pain (29%). Preoperative magnetic resonance imaging showed spinal cord enlargement with T2-hyperintensity (86%) and contrast enhancement (57%) at the cervical (14%), thoracolumbar (57%), and/or conus medullaris (57%) level. Prebiopsy spinal angiogram, performed in two patients, was negative. Spinal cord biopsy showed architecturally distorted parenchyma with gliosis and thick hyalinized vessels (100%), variable myelin loss (71%), mild glial atypia (57%), hemosiderin deposition (71%), Rosenthal fibers (43%), vascular thrombosis (29%), and necrosis (29%), features highly suggestive of venous congestive myelopathy. Postbiopsy spinal angiograms were performed in five patients. A dural arteriovenous fistula was identified by selective angiography in three patients, including the two with a negative preoperative angiogram. Additional postbiopsy angiographic studies in two patients were negative, and two patients were followed up without angiography. Mean follow-up after biopsy was 13.6 months. Histologic changes characteristic of venous congestive myelopathy may be seen in spinal cord biopsies with or without an associated fistula. Recognition of this entity by surgical pathologists is important, leading to the correct identification of a non-neoplastic lesion as well as of a surgically treatable disease.

Intracranial dural arteriovenous fistula presenting with tetraparesis due to cervicomedullary junction compression. A case report

SUMMARY

Cranial dural arteriovenous fistulas (DAVFs) may give rise to myelopathy due to spinal perimedullary venous drainage causing intramedullary venous hypertension. Such cases are uncommon but not rare, with several cases reported in the literature. We report a case of foramen magnum DAVF presenting with symptoms of tetraparesis. The unusual feature was that in this case it was due to compression of the cervicomedullary junction by a large venous pouch rather than the result of spinal perimedullary venous hypertension. Transarterial glue embolization achieved good reduction of flow in the fistula with shrinkage of the venous pouch and corresponding clinical improvement.