Pediatric perimedullary arteriovenous fistula of the conus medullaris supplied by the artery of Desproges-Gotteron

Distinctive Characteristics of Thoracolumbar Junction Region Stenosis

STUDY DESIGN

Retrospective case series and systemic literature meta-analysis.

BACKGROUND

Thoracolumbar junction region stenosis produces spinal cord compression just above the conus and may manifest with symptoms that are not typical of either thoracic myelopathy or neurogenic claudication from lumbar stenosis.

OBJECTIVE

As few studies describe its specific pattern of presenting symptoms and neurological deficits, this investigation was designed to improve understanding of this pathology.

METHODS

A retrospective review assessed surgically treated cases of T10-L1 degenerative stenosis. Clinical outcomes were evaluated with the thoracic Japanese Orthopedic Association score. In addition, a systematic review and meta-analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Of 1069 patients undergoing laminectomy at 1477 levels, 31 patients (16M/15F) were treated at T10-L1 a mean age 64.4 (SD=11.8). Patients complained of lower extremity numbness in 29/31 (94%), urinary dysfunction 11/31 (35%), and back pain 11/31 (35%). All complained about gait difficulty and objective motor deficits were detected in 24 of 31 (77%). Weakness was most often seen in foot dorsiflexion 22/31 (71%). Deep tendon reflexes were increased in 10 (32%), decreased in 11 (35%), and normal 10 (32%); the Babinski sign was present 8/31 (26%). Mean thoracic Japanese Orthopedic Association scores improved from 6.4 (SD=1.8) to 8.4 (SD=1.8) ( P <0.00001). Gait subjectively improved in 27/31 (87%) numbness improved in 26/30 (87%); but urinary function improved in only 4/11 (45%).

CONCLUSIONS

Thoracolumbar junction stenosis produces distinctive neurological findings characterized by lower extremity numbness, weakness particularly in foot dorsiflexion, urinary dysfunction, and inconsistent reflex changes, a neurological pattern stemming from epiconus level compression and the myelomeres for the L5 roots. Surgery results in significant clinical improvement, with numbness and gait improving more than urinary dysfunction. Many patients with thoracolumbar junction stenosis are initially misdiagnosed as being symptomatic from lumbar stenosis, thus delaying definitive surgery.

Characteristics and outcomes of pediatric dural arteriovenous fistulas: a systematic review

BACKGROUND

Dural arteriovenous fistulas (dAVF) are arteriovenous shunts in communication with the dural vasculature in the brain or spine. Apart from single-center series, risk factors and treatment outcomes for pediatric dAVFs are largely undescribed.

METHODS

We performed a systematic literature review of pediatric (< 18 years at diagnosis) intracranial and spinal dAVF according to PRISMA guidelines. We queried PubMed, CINAHL, SCOPUS, and Embase databases without time/date restriction. Search strings included a variety of MeSH keywords relating to dural AV fistulas in combination with MeSH keywords related to pediatric cases (see Appendix). Manuscripts describing patients diagnosed with dural sinus malformations or pial AVF were excluded.

RESULTS

We identified 61 studies describing 69 individual patients. Overall, dAVF were more common in males (55.1%) with a mean age of diagnosis (5.17 ± 4.42 years). Approximately 20.2% of patients presented with cardiovascular disease (CVD), and 31.9% were discovered incidentally on neuroimaging studies. Transverse-sigmoid junction was the most common location (17.3%). Ninety-three percent (64 patients) were treated, most commonly using endovascular embolization (68.1%) followed by surgery (8.7%) and radiosurgery (2.9%). Almost half (43.8%) of dAVFs were completely obliterated. Of the 64 procedures, there were 19 neurological complications (29.7%) of varying severity where 12.5% were considered transient (i.e., pseudomeningocele) and 17.2% permanent (i.e., mortality secondary to acute sinus thrombosis, etc.).

CONCLUSION

There is a paucity of information on pediatric dAVFs. This systematic review summarizes the published cases of dAVFs in the pediatric population. While the rate of missing data is high, there is publication bias, and precise details regarding complications are difficult to ascertain, this review serves as a descriptive summary of pediatric dAVFs.

Arteriovenous Malformation of Conus Medullaris Fed by the Artery of Desproges-Gotteron

Presence of the artery of Desproges-Gotteron is extremely rare. It has seldom been mentioned in the literature as well. The authors have dealt with a case of a dural arteriovenous malformation (AVM ) of conus medullaris fed by the artery of Desproges-Gotteron in a young female of 19 years. The patient presented with a tingling sensation of lower limbs, progressive difficulty walking, and incontinence of the bladder. There was weakness in all groups of muscle of both lower limbs and definite sensory level on examination. Magnetic resonance imaging revealed multiple flow voids at the level of conus medullaris. Spinal digital subtraction angiography (DSA) revealed dural AVM at the level of conus. The patient underwent transarterial embolization with 30% Endocryl( n -butyl cyanoacrylate) in two stages, and repeated spinal DSA revealed no evidence of residual AVM. Patient's neurology gradually improved. Almost 2 years down the line, the follow-up revealed gradual but complete motor and sensory deficits recovery except for occasional burning pain in lower limbs. Spinal AVM supplied by the artery of Desproges-Gotteron is a unique variation. Moreover, the authors believe that it is the first reported case in Bangladesh.

Spinal perimedullary arteriovenous fistula supplied by the artery of Desproges-Gotteron: A case report with literature review

Spinal perimedullary arteriovenous fistula (PAVF) of the conus medullaris and cauda equina supplied by the artery of Desproges-Gotteron (ADG) is rare. The present study reports such a rare case and also presents a brief literature review. The patient described herein was a 31-year-old female. She suffered sudden weakness in the lower limbs, a condition which was then gradually aggravated. A physical examination revealed paraplegia, and urination and defecation difficulties. Spinal magnetic resonance imaging (MRI) and computed tomography angiography (CTA) revealed extensive perimedullary vein dilation with the involvement of the ADG as the main feeding artery. Digital subtraction angiography (DSA) confirmed a high-flow PAVF supplied by the ADG and artery of Adamkiewicz (AKA). Microsurgical treatment under intraoperative DSA assistance was performed. The PAVF was resected, and immediately following DSA confirmed the complete removal of the PAVF. Following discharge, the patient was prescribed rehabilitation exercises and gradually recovered. A follow-up CTA and MRI confirmed that the PAVF was cured, and her modified Rankin scale score was 2. Therefore, as demonstrated herein, microsurgery with intraoperative DSA assistance may be considered an effective treatment option for PAVFs with ADG.

Diagnosis and Endovascular Embolization of a Sacral Spinal Arteriovenous Fistula with "Holo-Spinal" Venous Drainage

BACKGROUND

Spinal dural arteriovenous fistulas are the most common spinal vascular pathology, accounting for up to 70% of spinal vascular malformations. They most commonly present with insidious and progressive myelopathy and bowel, bladder, and sexual dysfunction. Although noninvasive imaging (e.g., magnetic resonance imaging, magnetic resonance angiography) may suggest the presence of a spinal arteriovenous fistula (AVF), the diagnosis requires confirmation with spinal angiography.

CASE DESCRIPTION

A 65-year-old woman presented with progressive myelopathy. Traditional spinal angiography of the paired radicular arteries failed to demonstrate any vascular malformation. However, injection of the right internal iliac artery demonstrated an AVF arising from the artery of Desproges-Gotteron with retrograde venous drainage to the upper thoracic region.

CONCLUSIONS

Selective transarterial catheterization and embolization with n-butyl cyanoacrylate resulted in complete occlusion of the AVF. Clinical improvement was also noted on postprocedural day 1. This case highlights the importance of internal iliac injections as a critical component of spinal angiography during an evaluation for vascular malformation.

Study and therapeutic progress on spinal cord perimedullary arteriovenous fistulas

Spinal cord perimedullary arteriovenous fistulas (PMAVFs) are rare and belong to type IV spinal cord arteriovenous malformations (AVMs). Little is known regarding the treatment and prognosis of spinal cord PMAVFs. In the present study the relevant literature from PubMed was reviewed, and it was found that these fistulas can occur at all ages but are more common in children. In children, most spinal cord PMAVFs are large and with high flow, begin with bleeding and are frequently associated with hereditary hemorrhagic telangiectasia. However, in adults, most spinal cord PMAVFs are small and with low flow and begin with progressive spinal cord dysfunction. The early diagnosis of spinal cord PMAVFs is generally difficult, and symptoms can be very severe at the time of diagnosis. Digital subtraction angiography remains the gold standard; however, computed tomography angiography and magnetic resonance angiography are also promising. Spinal cord PMAVFs can be treated by endovascular embolization, surgical removal or a combination of the two methods. Most spinal cord PMAVFs show good outcomes after the appropriate treatment, and the prognosis is primarily associated with the blood flow of the PMAVF. For high-flow spinal cord PMAVFs, endovascular embolization is more effective and can lead to a good outcome; however, for low-flow spinal cord PMAVFs, surgical removal or the combination with endovascular embolization is the optimal choice. The prognosis for low-flow types is slightly worse than for high-flow spinal cord PMAVFs in children, but the outcome is acceptable.