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Ikeuchi Y, Fujita A, Kohta M, Yamanishi S, Tanaka K, Sasayama T. Multiple Synchronous Spinal Dural Arteriovenous Fistulas: A Systematic Literature Review. Neurosurgery 2024:00006123-990000000-01136. [PMID: 38647293 DOI: 10.1227/neu.0000000000002958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/01/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Spinal dural arteriovenous fistulas (SDAVFs) lead to progressive neurological decline with symptoms such as paraparesis, bowel and bladder dysfunction, and sensory disturbances because of impaired spinal cord venous drainage. This study aimed to systematically review the literature on multiple synchronous SDAVFs and present 2 cases from our institution. METHODS A comprehensive search was performed to identify all published cases of multiple synchronous SDAVFs. Overall, 23 patients with multiple synchronous SDAVFs were identified, including 21 from 19 articles and 2 from this study. The clinical presentation, lesion location, radiographic features, surgical treatment, and outcomes were analyzed in each patient. RESULTS All patients in this study were male, and the duration from symptom onset to diagnosis in many of these patients was longer than that previously reported. Previous studies suggested that multiple SDAVFs typically occurred within 3 or fewer vertebral levels. However, >50% of the examined patients had remote lesions separated by more than 3 vertebral levels. Patients with remote lesions had a significantly worse outcome (1/7 vs 8/11, 95% CI 0.001-0.998; P = .049). CONCLUSION Accurately locating fistulas before spinal angiography is critical for managing multiple remote SDAVFs. Considering the possibility of multiple remote SDAVFs, careful interpretation of imaging findings is essential for an accurate diagnosis and appropriate treatment planning.
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Affiliation(s)
- Yusuke Ikeuchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
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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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Hedjoudje A, Peng X, Gautam A, Pardo CA, Sciubba D, Gailloud P. Case of Cowden Syndrome with 15 Spinal Arteriovenous Fistulas. World Neurosurg 2020; 139:567-576. [PMID: 32344142 DOI: 10.1016/j.wneu.2020.04.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spinal vascular malformations are rarely multiple: fewer than 50 observations have been documented so far, with a maximum of 4 coexisting lesions per patient, always restricted to a single vertebral region (e.g., cervical or thoracic). CASE DESCRIPTION We describe the case of a 61-year-old woman with Cowden syndrome with 15 spinal arteriovenous fistulas (AVFs) at the cervical, thoracic, and lumbar levels and an adrenal AVF. She was initially referred for reevaluation of an upper cervical spinal epidural spinal arteriovenous fistula diagnosed 6 years earlier. Her history included breast carcinoma, a malignant salivary gland tumor, and removal of multiple ovarian, thyroid, and gastric hamartomas. Computed tomography and magnetic resonance imaging confirmed the presence of a prominent cervical vascular lesion. Spinal digital subtraction angiography revealed the presence of 15 additional vascular anomalies. CONCLUSIONS This multiplicity of AVFs appears to result from a combination of various factors including local regional hemodynamic changes, growth factor-mediated alterations involving notably vascular endothelial growth factor pathways, and the prothrombotic state associated with abnormalities in blood vessel structure.
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Affiliation(s)
- Abderrahmane Hedjoudje
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
| | - Xiao Peng
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ayushi Gautam
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Carlos A Pardo
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Sciubba
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Zhong W, Zhang J, Shen J, Su W, Wang D, Zhang P, Wang Y. Dural Arteriovenous Fistulas at the Craniocervical Junction: A Series Case Report. World Neurosurg 2018; 122:e700-e712. [PMID: 30385361 DOI: 10.1016/j.wneu.2018.10.124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Craniocervical junction dural arteriovenous fistulas (CJDAVFs) are rare vascular malformations with unclear clinical characteristics. This study investigated the clinical characteristics and outcomes of patients with CJDAVFs. METHODS Thirty-eight patients with CJDAVFs who had undergone either conservative or surgical treatment were retrospectively analyzed. RESULTS Eleven (28.9%) patients were women and 27 (71.1%) were men (median age, 52.5 years). Two (5.3%) had myelopathy, and 36 (94.7%) had subarachnoid hemorrhage (SAH). Three patients had SAH recurrence before treatment. Five patients (13.9%) with SAH initially had negative results on angiography, which may have been due to a low-flow fistula without varicose veins (P = 0.034) and acute hydrocephalus (P = 0.084). Coincidental vascular lesions were noted in 5 patients (13.2%). Caudal drainage was mainly found in patients with myelopathy, whereas superolateral drainage was frequently observed in patients with SAH (P = 0.021). Thirty-six (94.7%) patients underwent microsurgery; of these, 33 (91.7%) had favorable outcomes and 3 (8.3%) had unfavorable outcomes. The main neurosurgical complications included acute hydrocephalus in 4 (10.5%) and new-onset mild persistent myelopathy in 6 (15.7%). According to the univariate analysis, the presence of myelopathy predicted poor outcomes, whereas SAH predicted favorable outcomes (P = 0.004). However, the multivariate analysis did not show statistical significance. CONCLUSIONS SAH is a common presenting sign of CJDAVF that may be overlooked on initial cerebral angiography, especially in patients with acute hydrocephalus and a low-flow fistula without varicose veins. Microsurgery involving disconnecting the draining vein is effective and beneficial. Further studies should be performed to investigate predictive factors influencing the prognosis.
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Affiliation(s)
- Weiying Zhong
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, P. R. China
| | - Ji Zhang
- Department of Neurosurgery, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, P. R. China
| | - Jie Shen
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, P. R. China
| | - Wandong Su
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, P. R. China
| | - Donghai Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, P. R. China
| | - Ping Zhang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, P. R. China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, P. R. China.
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Jablawi F, Mull M. Double spinal dural arteriovenous fistulas. J Neuroradiol 2018; 46:168-172. [PMID: 30389511 DOI: 10.1016/j.neurad.2018.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 07/04/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Spinal dural arteriovenous fistulas (SDAVF) are usually solitary lesions. Synchronous and/or metachronous double SDAVF have rarely been reported in the literature. We report on three patients with double SDAVF and present our single center experience in the diagnostic and treatment management in these patients. MATERIAL AND METHODS We retrospectively revised our medical database for all patients who were diagnosed and treated in our center due to a SDAVF between 1990 and 2017. All data including demographics, clinical presentations, as well as radiological data were re-evaluated for this study. RESULTS Three (1.4%) of 209 consecutive patients with SDAVF presented double SDAVF with different arterial feeders and venous drainage patterns. All three patients were men. The mean age at time of diagnosis was 67.9 ± 10 years (median; 68, range: 53-82). Myelopathic symptoms were reported in all three cases. All three fistulas were located in the thoracolumbar region between T7 and L2. MRI/CE-MRA showed medullar T2-hyperintensity, intramedullary contrast-enhancement and dilatation of perimedullary veins in various extensions. CONCLUSION Double SDAVF are extremely rare and were found in 1.4% of patients in our series. The vast majority of the reported double SDAVF in the literature has been detected synchronously within an area of equal or less than three vertebral levels. Thus, whenever the SDAVF is identified, further injections of the fistula-zone neighbored segmental arteries might be recommended. However, due to the extremely low incidence of double SDAVF a complete spinal DSA is not indicated.
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Affiliation(s)
- F Jablawi
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Pauwelsstrasse, 30, 52074 Aachen, Germany; Department of Neurosurgery, Justus-Liebig-University, Klinikstrasse, 33, 35392 Giessen, Germany
| | - M Mull
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Aachen, Pauwelsstrasse, 30, 52074 Aachen, Germany.
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Remote Lesions of Synchronous Sacral and Cervical Dural Arteriovenous Fistulas: A Case Report. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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McGuinness BJ, Morrison JP, Brew SK, Moriarty MW. Benign Enhancing Foramen Magnum Lesions: Clinical Report of a Newly Recognized Entity. AJNR Am J Neuroradiol 2017; 38:721-725. [PMID: 28154124 DOI: 10.3174/ajnr.a5085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/03/2016] [Indexed: 11/07/2022]
Abstract
Intradural extramedullary foramen magnum enhancing lesions may be due to meningioma, nerve sheath tumor, aneurysm, or meningeal disease. In this clinical report of 14 patients, we describe a novel imaging finding within the foramen magnum that simulates disease. The lesion is hyperintense on 3D-FLAIR and enhances on 3D gradient-echo sequences but is not seen on 2D-TSE T2WI. It occurs at a characteristic location related to the posterior aspect of the intradural vertebral artery just distal to the dural penetration. Stability of this lesion was demonstrated in those patients who underwent follow-up imaging. Recognition of this apparently benign lesion may prevent unnecessary patient anxiety and repeat imaging.
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Affiliation(s)
- B J McGuinness
- From Trinity MRI (B.J.M., J.P.M., S.K.B., M.W.M.), Auckland, New Zealand .,Neuroradiology Section (B.J.M., S.K.B., M.W.M.), Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - J P Morrison
- From Trinity MRI (B.J.M., J.P.M., S.K.B., M.W.M.), Auckland, New Zealand
| | - S K Brew
- From Trinity MRI (B.J.M., J.P.M., S.K.B., M.W.M.), Auckland, New Zealand.,Neuroradiology Section (B.J.M., S.K.B., M.W.M.), Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - M W Moriarty
- From Trinity MRI (B.J.M., J.P.M., S.K.B., M.W.M.), Auckland, New Zealand.,Neuroradiology Section (B.J.M., S.K.B., M.W.M.), Department of Radiology, Auckland City Hospital, Auckland, New Zealand
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Avecillas-Chasín JM, Brin JR, Lopez-Ibor L, Gomez G, Rodriguez-Boto G. Multiple spinal arteriovenous fistulas: A case-based review. Clin Neurol Neurosurg 2015; 139:6-11. [DOI: 10.1016/j.clineuro.2015.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/13/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022]
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