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Swain SK, Arora RK, Sharma SK, Nandolia K, Basu G, Rekhapalli R, Arora P, Rajpal G, Sherwani P, Saxena S, Mittal RS. Vertebral arteriovenous fistulae in neurofibromatosis type1: a systematic review and meta-analysis. J Neurosurg Sci 2021; 66:54-61. [PMID: 33870666 DOI: 10.23736/s0390-5616.21.05232-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Vertebral Arterio-venous fistulas (VAVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. Among spontaneous cases, it is most commonly found to be associated with Neurofibromatosis type 1 (NF1). EVIDENCE ACQUISITION We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities and outcome of VAVFs associated with NF1. A literature search was performed by using databases PubMed Central, Embase, Cochrane Library, and Ovid MEDLINE. Also, the grey area search was done using the "Google Scholar" search engine. On screening of the original full-text English language articles, a total of 48 cases were considered suitable for inclusion in this review. EVIDENCE ANALYSIS VAVFs in NF1 commonly present between 3rd and 6th decade of life affecting females 2.4 times more than males. Left-sided fistulae were more common than the right side and most seen in the upper V2 segment of the vertebral artery. Most VAVFs in NF 1 patients were treated with constructive (occlusion of fistula only) endovascular therapy (n =26) with a high success rate. Moreover, Pooled proportion of the outcome data have shown significant difference between the endovascular constructive and destructive procedure. CONCLUSIONS The spontaneous VAVF, commonly associated with NF-1, often requires treatment. Awareness of the coexistence between NF1 and VAVF is crucial to avoid diagnostic delays and unnecessary surgical intervention leading to disastrous outcomes. Endovascular treatment is the preferred treatment approach while open surgical treatment is required in some complex fistulae and failure of endovascular techniques.
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Affiliation(s)
- Srikant K Swain
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Rajnish K Arora
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India -
| | | | - Khanak Nandolia
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Garga Basu
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Rajasekhar Rekhapalli
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
| | - Poonam Arora
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Rishikesh, India
| | - Girish Rajpal
- Neurointerventionist, Max Healthcare, New Delhi, India
| | - Poonam Sherwani
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Sudhir Saxena
- Department of Radiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Radhey S Mittal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, India
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Intercostal aneurysm causing spinal cord compression in an NF1 patient. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 24:940-4. [PMID: 23604938 DOI: 10.1007/s00586-013-2778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 03/10/2013] [Accepted: 04/03/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The authors illustrate a case where an intercostal aneurysm was observed in a patient with type 1 neurofibromatosis. METHODS A 32-year-old man with NF1 presented with thoracic back pain. The patient's symptoms progressed to include myelopathic symptoms, including difficulty urinating, numbness in the lower extremities, and increased weakness. Imaging revealed what appeared to be a neurofibroma at the T4-T5 level and a plan to resect the mass was formulated. Upon initial limited hemilaminotomy, significant arterial blood was encountered. The patient was then taken to the interventional suite and angiography was performed, revealing a left T4 intercostal aneurysm. The aneurysm was coil-embolized with no residual filling. RESULTS By 6 months post-surgery, the patient had regained full strength and sensation in his lower extremities and no longer had difficulty urinating. There has been no recurrence of symptoms 3 years postoperatively. CONCLUSIONS Intercostal artery lesions must be considered as a possible diagnosis in NF1.
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Higa G, Pacanowski JP, Jeck DT, Goshima KR, León LR. Vertebral artery aneurysms and cervical arteriovenous fistulae in patients with neurofibromatosis 1. Vascular 2010; 18:166-77. [PMID: 20470689 DOI: 10.2310/6670.2010.00032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Vascular involvement in the setting of neurofibromatosis type 1(NF1) has been well described. However, the coexistence of NF1 with vertebral artery (VA) aneurysms and arteriovenous fistulae (AVFs) is a rare occurrence. A 60-year-old female with NF1 and other severe comorbidities presented with acute respiratory insufficiency caused by a ruptured large VA aneurysm and an associated AVF that required emergent intubation and eventual repair through endovascular techniques that resolved her symptoms. A detailed description of this case and a comprehensive review of the literature are also presented.
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Revencu N, Boon LM, Mulliken JB, Enjolras O, Cordisco MR, Burrows PE, Clapuyt P, Hammer F, Dubois J, Baselga E, Brancati F, Carder R, Quintal JMC, Dallapiccola B, Fischer G, Frieden IJ, Garzon M, Harper J, Johnson-Patel J, Labrèze C, Martorell L, Paltiel HJ, Pohl A, Prendiville J, Quere I, Siegel DH, Valente EM, Van Hagen A, Van Hest L, Vaux KK, Vicente A, Weibel L, Chitayat D, Vikkula M. Parkes Weber syndrome, vein of Galen aneurysmal malformation, and other fast-flow vascular anomalies are caused by RASA1 mutations. Hum Mutat 2008; 29:959-65. [PMID: 18446851 DOI: 10.1002/humu.20746] [Citation(s) in RCA: 266] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Capillary malformation-arteriovenous malformation (CM-AVM) is a newly recognized autosomal dominant disorder, caused by mutations in the RASA1 gene in six families. Here we report 42 novel RASA1 mutations and the associated phenotype in 44 families. The penetrance and de novo occurrence were high. All affected individuals presented multifocal capillary malformations (CMs), which represent the hallmark of the disorder. Importantly, one-third had fast-flow vascular lesions. Among them, we observed severe intracranial AVMs, including vein of Galen aneurysmal malformation, which were symptomatic at birth or during infancy, extracranial AVM of the face and extremities, and Parkes Weber syndrome (PKWS), previously considered sporadic and nongenetic. These fast-flow lesions can be differed from the other two genetic AVMs seen in hereditary hemorrhagic telangiectasia (HHT) and in phosphatase and tensin homolog (PTEN) hamartomatous tumor syndrome. Finally, some CM-AVM patients had neural tumors reminiscent of neurofibromatosis type 1 or 2. This is the first extensive study on the phenotypes associated with RASA1 mutations, and unravels their wide heterogeneity.
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Affiliation(s)
- Nicole Revencu
- Laboratory of Human Molecular Genetics, de Duve Institute, Université catholique de Louvain, Brussels, Belgium
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Paolini S, Colonnese C, Galasso V, Morace R, Tola S, Esposito V, Cantore G. Extradural arteriovenous fistulas involving the vertebral artery in neurofibromatosis Type 1. J Neurosurg Spine 2008; 8:181-5. [DOI: 10.3171/spi/2008/8/2/181] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ Spinal extradural arteriovenous fistulas (AVFs) are rare lesions that may be associated with neurofibromatosis Type 1 (NF1). In these patients, the shunt typically occurs between the V2 segment of the vertebral artery and the epidural venous plexus. Previously, reported cases have been treated either by using endovascular embolization or, sporadically, by open surgery. In surgical reports, proximal deafferentation or manipulation of the venous portion of the shunt—including suture, resection, or open embolization of the epidural ectasia—was attempted with variable results. The authors report on a case of a young patient with NF1 who underwent emergency surgical disconnection of a cervical extradural AVF after previously unsuccessful endovascular and surgical therapy. The lesion drained into a giant intrathecal varix, causing severe myelopathy. After surgery, the patient recovered almost completely. This experience clarified the surgical anatomy of these malformations and showed that, when surgery is necessary, the optimal treatment providing complete and permanent cure of this condition is direct closure of the epidural shunt pedicle.
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Affiliation(s)
- Sergio Paolini
- 1Department of Neurosurgery, IRCCS Neuromed Pozzilli, University of Perugia; and
| | | | | | - Roberta Morace
- 3Neurosurgery, IRCCS Neuromed Pozzilli, University of Rome “La Sapienza,” Rome, Italy
| | - Serena Tola
- 3Neurosurgery, IRCCS Neuromed Pozzilli, University of Rome “La Sapienza,” Rome, Italy
| | - Vincenzo Esposito
- 3Neurosurgery, IRCCS Neuromed Pozzilli, University of Rome “La Sapienza,” Rome, Italy
| | - Giampaolo Cantore
- 3Neurosurgery, IRCCS Neuromed Pozzilli, University of Rome “La Sapienza,” Rome, Italy
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Pereira VM, Geiprasert S, Krings T, Caldas JGMP, Toulgoat F, Ozanne A, Mercier P, Lasjaunias PL. Extracranial vertebral artery involvement in neurofibromatosis type I. Report of four cases and literature review. Interv Neuroradiol 2007; 13:315-28. [PMID: 20566100 PMCID: PMC3329237 DOI: 10.1177/159101990701300402] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2007] [Accepted: 11/12/2007] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Neurofibromatosis type 1 (NF-1) is one of the most common inherited diseases and as an autosomal dominant genetic disorder results from NF-1 gene mutation with 100% penetration and wide phenotypic variability. The disease can involve a wide variety of tissues derived from all three embryonic layers. NF-1 vasculopathy has been described primarily in peripheral arteries, but arteries supplying the CNS may also be involved. Of those, extracranial vertebral involvement is the commonest and most important. A series of four patients with NF-1 and vascular disease of the vertebral artery is described with a review of the pathophysiology, vascular phenotypes, their management and the pertinent literature.
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Affiliation(s)
- V M Pereira
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, Le Kremlin-Bicetre, Paris, France - Department of Neuroradiology, University of Sao Paulo, Brasil -
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Saito A, Takahashi T, Ezura M, Tominaga T. INTERCOSTAL ARTERIOVENOUS FISTULA ASSOCIATED WITH NEUROFIBROMATOSIS MANIFESTING AS CONGESTIVE MYELOPATHY. Neurosurgery 2007; 61:E656-7; discussion E657. [PMID: 17881941 DOI: 10.1227/01.neu.0000290918.47847.9e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Vascular abnormalities associated with neurofibromatosis Type 1 (NF-1) are well known, but arteriovenous fistulae (AVF) are rare and usually involve vertebral AVF. A case of intercostal AVF associated with NF-1 and manifesting as congestive myelopathy is described.
CLINICAL PRESENTATION
A 62-year-old woman with a medical history of NF-1 experienced gradually worsening gait disturbance. Neurological examination at the time of admission found spastic paraparesis, decrease of sensation in the bilateral lower extremities, and vesicorectal disturbance. Magnetic resonance imaging scans revealed flow void sign and a congestive lesion of the thoracolumbar spinal cord, as well as a huge mass in the paravertebral region at T10–T12. Spinal angiography revealed an intercostal AVF with a large paravertebral varix, which drained to the spinal medullary vein and caused dilation of the intradural venous plexus of the spinal cord resulting in congestive myelopathy.
INTERVENTION
Direct surgery was selected for the occlusion of the draining point of the medullary vein, located in the entry of the dura. The patient underwent hemilaminectomy at T10–T12, and the dural entry of the draining vein was occluded. Postoperative angiography revealed no dilated venous plexus of the spinal cord and reduced paravertebral varix. The symptoms were gradually relieved after the surgery.
CONCLUSION
The present case of a very rare intercostal AVF with an unusual manifestation of congestive myelopathy occurred in a relatively rare association with NF-1. Accurate evaluation of the vascular anomaly allowed selection of the appropriate surgical method.
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Affiliation(s)
- Atsushi Saito
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan.
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Hauck EF, Nauta HJW. Spontaneous spinal epidural arteriovenous fistulae in neurofibromatosis type-1. ACTA ACUST UNITED AC 2006; 66:215-21. [PMID: 16876638 DOI: 10.1016/j.surneu.2006.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 12/29/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND NF-1 is one of the most common autosomal-dominantly inherited genetic disorders with an incidence of approximately 1:3500. We report a case and review the literature to characterize spontaneous spinal AVF that occur in neurofibromatosis (NF-1). CASE REPORT A 51-year-old woman presented with NF-1 and progressive radiculomyelopathy. Angiography revealed an AVF terminating in a giant intraspinal epidural varix extending paraspinally through the C3/4 neural foramen. Trapping of the AVF attempted 18 years earlier prevented endovascular access for embolization, and vigorous bleeding made direct surgical resection impossible. Therefore, as palliation, arterial feeding collaterals were occluded, and surgically exposed tortuous veins were packed with coils. Laminectomies and partial resection of the epidural varix resulted in subtotal occlusion with clinical improvement. CONCLUSION The spinal AVF associated with NF-1 appears to show dominant venous drainage to the intraspinal extradural and paraspinal venous plexus without evidence of intradural drainage. The vertebral artery is typically the origin of the fistula. A giant venous varix and numerous collateral feeders to the vertebral artery may give an AVM-like appearance. Clinically, the fistulae produce a syndromic triad including symptoms of NF-1, progressive radiculomyelopathy, and a bruit. Treatment is direct attack on the fistula by either surgery or embolization. If, however, a direct approach cannot be chosen, occlusion of feeding vessels combined with laminectomies can result in long-term symptomatic improvement.
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Affiliation(s)
- Erik F Hauck
- Division of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555-0517, USA.
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Nadig M, Munshi I, Short MP, Tonsgard JH, Sullivan C, Frim DM. A child with neurofibromatosis-1 and a lumbar epidural arteriovenous malformation. J Child Neurol 2000; 15:273-5. [PMID: 10805199 DOI: 10.1177/088307380001500417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 10-year-old child with neurofibromatosis-1 was evaluated for progressive lumbar scoliosis, back pain, and foot numbness. Magnetic resonance imaging showed several lumbar intraspinal and extraspinal masses consistent with neurofibromas. The mass at L3-L5 compressed the thecal sac and was thought to be the source of the symptoms. On operative exploration, a lumbar epidural arteriovenous malformation was found, which was removed in its entirety. The child's back pain and foot numbness resolved. Epidural arteriovenous malformations in patients with neurofibromatosis-1 are rare and have been reported only in the cervical spine. Our finding of a lumbar epidural arteriovenous malformation in a child with neurofibromatosis-1 demonstrates that vascular anomalies can be present throughout the spine of patients with neurofibromatosis-1 and should be considered in the differential diagnosis of any neurofibromatosis-1-related epidural mass.
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Affiliation(s)
- M Nadig
- Pritzker School of Medicine, University of Chicago Children's Hospital, Illinois 60637, USA
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Koenigsberg RA, Aletich V, Debrun G, Camras LR, Ausman JI. Cervical vertebral arteriovenous fistula balloon embolization in a patient with neurofibromatosis type 1. SURGICAL NEUROLOGY 1997; 47:265-73. [PMID: 9068698 DOI: 10.1016/s0090-3019(96)00254-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The authors present a patient with neurofibromatosis type 1 associated with cervical kyphosis, a cervical vertebral arterial fistula, and contralateral vertebral arterial occlusion. The fistula was successfully treated with detachable balloons.
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Affiliation(s)
- R A Koenigsberg
- Department of Radiological Sciences, Allegheny University-MCP Division, Philadelphia, PA 19129, USA
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Cluzel P, Pierot L, Leung A, Gaston A, Kieffer E, Chiras J. Vertebral arteriovenous fistulae in neurofibromatosis: report of two cases and review of the literature. Neuroradiology 1994; 36:321-5. [PMID: 8065582 DOI: 10.1007/bf00593272] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Vertebral arteriovenous fistulae in patients with neurofibromatosis 1 (von Recklinghausen's disease) are rare. The mechanism of their formation is unclear. The vascular anatomy, which may be simple or complex has important implications for planning treatment. We describe two cases and review the literature.
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Affiliation(s)
- P Cluzel
- Service de Neuroradiologie Charcot, Hôpital de la Salpétrière, Paris, France
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Schievink WI, Michels VV, Piepgras DG. Neurovascular manifestations of heritable connective tissue disorders. A review. Stroke 1994; 25:889-903. [PMID: 8160237 DOI: 10.1161/01.str.25.4.889] [Citation(s) in RCA: 200] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Heritable disorders of connective tissue are recognized in a small minority of patients with neurovascular diseases. In this report, we review the neurovascular manifestations of four heritable connective tissue disorders: Ehlers-Danlos syndrome, Marfan's syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum, as well as two other systemic disorders with potential vascular manifestations: neurofibromatosis and polycystic kidney disease. SUMMARY OF REVIEW Typical neurovascular complications of Ehlers-Danlos syndrome are carotid-cavernous fistulae, intracranial aneurysms, and cervical artery dissections. Arterial dissections and intracranial aneurysms cause the majority of neurovascular symptoms in Marfan's syndrome. Neurovascular disease is uncommon in osteogenesis imperfecta, although carotid-cavernous fistulae and vertebral artery dissections have been reported. Neurovascular disease in pseudoxanthoma elasticum is characterized by intracranial aneurysms and cerebral ischemia caused by premature arterial occlusive disease. Intracranial occlusive arterial disease is the most common neurovascular manifestation of neurofibromatosis, followed by cervical arteriovenous fistulae and aneurysms and intracranial aneurysms. Intracranial aneurysms are the hallmark of polycystic kidney disease. CONCLUSIONS Recognition of an underlying generalized connective tissue disorder may be of considerable importance, although marked phenotypic heterogeneity often complicates the diagnosis of these disorders. Conversely, the association of certain neurovascular anomalies with generalized connective tissue disorders and recognition of their basic molecular defect may offer clues to the etiology and pathogenesis of these neurovascular diseases in general.
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Affiliation(s)
- W I Schievink
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minn. 55905
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