Acute spinal cord infarction: vascular steal in arteriovenous malformation

Insights into retinal hemangioblastoma using ultra widefield imaging

Purpose:

Retinal hemangioblastomas (RHs) are characteristic of von Hippel-Lindau (VHL) disease. Early diagnosis of retinal lesions may aid in systemic diagnosis. Early identification of VHL is life-saving and also prevents vision loss. Fundus fluorescein angiography (FFA) is a useful tool in the diagnosis and management of RHs. The aim of this study is to report FFA features of RH using ultra-widefield (UWF) imaging.

Methods:

A retrospective cross-sectional study of consecutive patients of RH who underwent UWF FFA at a tertiary eye care center. Images were analyzed and assessed by authors. The main outcome measures were (a) the number and size of RH in each eye and (b) vascular characteristics of the retina. UWF-FFA characteristics in each eye were tabulated. The number of clock hours involved by these characteristics and their correlation with the number and size of RH were analyzed.

Results:

The study evaluated 24 eyes of 13 patients. The mean age was 28.4 years. The median number of RHs in an eye was 3.5 (range 1–16), and the size of RHs varied from 0.1 to 4 disc diameters. Novel UWF-FFA findings noted in this study were the presence of abnormal capillary network in 22 of 24 eyes (91.7%), capillary leakage in 15 of 24 eyes (62.5%), and capillary telangiectasia in 7 of 24 eyes (29.2%). In addition, feeder arterioles and venules showed bulbous projections in 8 of 24 eyes (33.3%).

Conclusion:

The UWF-FFA characteristics of RH, which have not been described before, were identified. These add to our understanding of the pathogenesis of the disease and may pave the way for future therapeutic targets.

Classification and pathophysiology of spinal vascular malformations

Spinal arteriovenous malformations and fistulas comprise spinal vascular malformations (sVMs), a rare but challenging neurosurgic entity. A number of mechanisms have been proposed as explanations of neurologic decline in the setting of arteriovenous shunting, including venous hypertension, venous congestion, hemorrhage, vascular steal, or mass effect, which can be worsened with venous varices or aneurysmal dilations. Anatomic location and features dictate the categorization of sVMs. Two major systems are in place for classification of sVMs - (1) the American/French/English connection and (2) the Spetzler system - as well as a number of systems that have been described over the past century.

Spinal cord infarction following minor trauma in children: fibrocartilaginous embolism as a putative cause

Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

Non-traumatic spinal cord ischaemia in childhood - clinical manifestation, neuroimaging and outcome

BACKGROUND

Spinal cord ischaemia is rare in childhood and information on clinical presentation and outcome is scarce.

METHODS

This is a retrospective analysis of eight patients and 75 additional cases from the literature. Data search included: patient's age, primary manifestation, risk factors, neuroimaging and outcome.

RESULTS

Five female and three male patients gave consent to participate. Mean age was 12.5 years (10-15 years). Six patients presented with paraplegia; this was preceded by pain in four. Brown Sequard syndrome and quadriparesis were the two others' presenting condition. Sensation levels were thoracolumbar in seven cases. Bladder dysfunction only or bladder and bowel dysfunction were reported in eight and five patients respectively. Time to maximal symptom manifestation was <12 h in 7/8. Risk factors included surgery, minor trauma, recent infection, and thrombophilia. Mean follow-up was 3.3 years (0.25-6.3 years). Three patients remained wheelchair-dependent and three patients were ambulatory without aid. Bladder function recovered fully in five children. Most affected aspects of quality of life were physical and mental well-being and self-perception. T2-weighted-MR images showed pencil-like hyperintensity (8/8) in sagittal and H-shaped or snake-eyes-like lesion (6/8) in axial views. Analyses of all 83 patients were in congruence with the above results of the study group.

CONCLUSION

Spinal cord ischaemia in childhood presenting with pain, paraplegia, and bladder dysfunction has high morbidity concerning motor problems and quality of life. Acute arterial ischaemic event in children seems similar to adult events with respect to clinical presentation and, surprisingly, also in outcome.

Delayed presentation of tetraparesis following posterior thoracolumbar spinal fusion and instrumentation for adolescent idiopathic scoliosis

STUDY DESIGN

Case report.

OBJECTIVE

We present a case of delayed tetraparesis in a patient after posterior spinal fusion for adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The reported rate of neural complications after scoliosis surgery is low. Intraoperative neuromonitoring is used to detect and prevent spinal cord injury.

METHODS

Review of medical record.

RESULTS

Delayed tetraparesis developed on the second postoperative day after unremarkable T3-L4 posterior fusion. MRI revealed evidence of cord ischemia at C4-C7. Angiogram revealed a hypervascular T4 body resulting in arteriovenous shunting into the epidural venous plexus.

CONCLUSION

Venous congestive myelopathy due to arteriovenous shunting or unrecognized syrinx are presented as possible etiologies of this patient's spinal cord injury. A preoperative MRI may have helped discern the cause of this patient's spinal cord injury.

Clinical characteristic of spinal vascular malformation in pediatric patients

OBJECTIVE

Seventy-two pediatric spinal vascular malformation cases were reviewed and the characteristics of their clinical symptoms, diagnoses, and therapies were analyzed.

MATERIALS AND METHODS

A thorough overview was compiled examining patient sex, age, location, history, development, treatment, clinical, and anatomical results.

RESULTS

Spinal cord arteriovenous malformation was the most common (44.4%) subtype to be seen in these pediatric patients, while subdural perimedullary arteriovenous fistula (23.6%) was the second, followed by Cobb's syndrome (13.9%) and intramedullary cavernous angioma (5.6%). No spinal dual arteriovenous fistulae were found in infants. The highest incidence was seen during the infant and adolescent periods. Sixty-nine cases were treated by surgeries, embolizations, or a combination of both, and 71.5% of them had improved.

CONCLUSIONS

Early diagnosis and treatment are required. Surgery and embolization, or a combination of the two, are the current candidates for treatment.

Ischemic spinal cord infarction in children without vertebral fracture

Spinal cord infarction in children is a rare condition that is becoming more widely recognized. There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment, and prognosis. The risk factors for pediatric ischemic spinal cord infarction include obstruction of blood flow associated with cardiovascular compromise or malformation, iatrogenic or traumatic vascular injury, cerebellar herniation, thrombotic or embolic disease, infection, and vasculitis. In many children, the cause of spinal cord ischemia in the absence of vertebral fracture is unknown. Imaging diagnosis of spinal cord ischemia is often difficult, due to the small transverse area of the cord, cerebrospinal fluid artifact, and inadequate resolution of magnetic resonance imaging. Physical therapy is the most important treatment option. The prognosis is dependent on the level of spinal cord damage, early identification and reversal of ischemia, and follow-up with intensive physical therapy and medical support. In addition to summarizing the literature regarding spinal cord infarction in children without vertebral fracture, this review article adds two cases to the literature that highlight the difficulties and controversies in the management of this condition.

Spinal cord arteriovenous shunts: from imaging to management

Spinal cord arteriovenous shunts (SCAVSs) are either fistulas or niduses that can be separated in four different groups according to their localization and relationship to the dura. Paraspinal AVSs are located outside the spine and are responsible for neurological symptoms because of cord compression by ertatic veins, venous congestion or arterial steal. Epidural shunts are located in the epidural space and drain in epidural veins with secondary intradural congestion. Dural shunts are embedded in the dura, produce a cord venous myelopathy after draining through veins that either pierce the dura far from a nerve root or accompany a nerve root. Intradural shunts affect the cord, the roots or the filum. Additionally, they can be classified according to their potential relationships with genetics, vascular biological features and angiogenesis into genetic hereditary lesions (hereditary hemorrhagic telangiectasia), genetic non-hereditary lesions (multiple lesions with metameric links) and single lesions (AVMs or micro AVFs). MRI and MRA are able to visualise SCAVS early after the onset of clinical symptoms. The type of shunt and its localization may remain difficult to be precise. Angiography remains the gold standard for analysis of the anatomical, morphological and architectural features necessary for therapeutic decisions in both paediatric and adult populations. In our series, embolisation is chosen in first intention whatever the type of shunt responsible for the clinical symptoms and glue is preferably used. In paraspinal, dural or epidural arteriovenous shunts, the goal of treatment should be complete closure of the shunt. A complete cure by embolization is rather easily achieved in paraspinal lesions. Failure of endovascular therapy in dural or epidural shunts must bring the patient to surgery. The prognosis of most intradural shunts seems better than previously thought, even after haemorrhage. In intradural spinal cord arteriovenous shunts, embolisation targeted towards the portions of the malformation felt to be responsible for the symptoms (venous congestion) or pointing to the point of rupture (false aneurysms) of the malformation, allows restoration of a new hemodynamic equilibrium between the malformation and the cord itself. Such targeted treatment offers long-term stabilisation or improvement to patients suffering from SCAVSs and good protection against (re) haemorrhages, with an acceptable morbidity. Cure of the shunt is not imperative to obtain these satisfactory outcomes. The clinical results obtained by such management compare favourably with those obtained by neurosurgery.