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Fiorenza V, Brunasso L, Ascanio F, Maugeri R, Odierna Contino A, Iacopino DG, Tringali G. Glomus Cervical Arteriovenous Malformation Presenting with Intracranial Subarachnoid Hemorrhage: Clinical Case and Pial Resection Surgical Technique Description. World Neurosurg 2023; 179:1-4. [PMID: 37499750 DOI: 10.1016/j.wneu.2023.07.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
Spinal intramedullary arteriovenous malformations (AVMs) can present with spinal hemorrhage. However, some of them occasionally can be the cause of angiographically negative intracranial subarachnoid hemorrhage, thus requiring a more comprehensive diagnostic approach to detect the possible source of bleeding. Nidal or arterial feeder aneurysms are widely considered high-risk rupture portions of the spinal AVM and recognized as a major cause of bleeding. Due to the tight eloquent confines within the thecal sac and the higher annual rupture risk after the initial bleeding, recurrent hemorrhage may have catastrophic outcomes. Hence the goal of management is to obliterate the spinal AVM preserving neurologic function and preventing future hemorrhagic events. Unlike cerebral AVMs, partial treatment of spinal intramedullary AVMs has been documented to be effective to improve the patients' prognosis dramatically. Microsurgical resection with or without adjuvant embolization has been considered the mainstay treatment for symptomatic glomus spinal intramedullary AVMs. The case of a 25-year-old man with acute cerebral subarachnoid hemorrhage caused by intranidal aneurysm rupture of cervical glomus-type AVM is presented here. The patient was surgically treated by C3-C4 laminectomy and AVM excision by pial resection technique. Thereby, the pial resection technique helps in providing subtotal AVM nidus resection, minimizing parenchymal dissection but effectively devascularizing glomus AVMs with satisfactory long-term results.
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Affiliation(s)
- Vito Fiorenza
- Department of Neurosurgery, ARNAS Civico Di Cristina, Palermo, Italy
| | - Lara Brunasso
- Neurosurgical Clinic, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neuroscience and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy.
| | - Francesco Ascanio
- Department of Neurosurgery, ARNAS Civico Di Cristina, Palermo, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neuroscience and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | | | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neuroscience and Advanced Diagnostics, School of Medicine, University of Palermo, Palermo, Italy
| | - Giovanni Tringali
- Department of Neurosurgery, ARNAS Civico Di Cristina, Palermo, Italy
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Abougamil A, L Srinivasan H, Fiandeiro CE, D C Kumar R, Bibby S, Booth TC, Hasegawa H, Walsh DC. Robotically facilitated parafasicular microsurgery to a brain arteriovenous malformation in a paediatric patient. Br J Neurosurg 2023:1-7. [PMID: 37652406 DOI: 10.1080/02688697.2023.2239902] [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: 06/05/2022] [Revised: 05/26/2023] [Accepted: 07/18/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE We report what we believe is the first application of robotically constrained image-guided surgery to approach a fistulous micro-arteriovenous malformation in a highly eloquent location. Drawing on institutional experience with a supervisory-control robotic system, a series of steps were devised to deliver a tubular retractor system to a deeply situated micro-arteriovenous malformation. The surgical footprint of this procedure was minimised along with the neurological morbidity. We hope that our contribution will be of assistance to others in integrating such systems given a similar clinical problem. CLINICAL PRESENTATION A right-handed 9-year old girl presented to her local emergency department after a sudden onset of severe headache accompanied by vomiting. An intracranial haemorrhage centred in the right centrum semiovale with intraventricular extension was evident and she was transferred urgently to the regional paediatric neurosurgical centre, where an external ventricular drain (EVD) was sited. A digital subtraction angiogram demonstrated a small right hemispheric arteriovenous shunt irrigated by peripheral branches of the middle cerebral artery & a robotically facilitated parafasicular microsurgical approach was performed to disconnect the arteriovenous malformation. CONCLUSION We describe the successful microsurgical in-situ disconnection of a deeply-situated, fistulous micro-AVM via a port system itself delivered directly to the target with a supervisory-control robotic system. This minimised the surgical disturbance along a relatively long white matter trajectory and demonstrates the feasibility of this approach for deeply located arteriovenous fistulae or fistulous AVMs.
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Affiliation(s)
- Ahmed Abougamil
- Department of Neurovascular Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Harishchandra L Srinivasan
- Department of Epilepsy and Functional Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Carlos E Fiandeiro
- Department of Neuroanaesthesia, King's College Hospital NHS Foundation Trust, London, UK
| | - Robin D C Kumar
- Department of Neuroanaesthesia, King's College Hospital NHS Foundation Trust, London, UK
| | - Steven Bibby
- Department of Interventional Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas C Booth
- Department of Interventional Neuroradiology, King's College Hospital NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Harutomo Hasegawa
- Department of Epilepsy and Functional Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
- Department of Paediatric Neurosurgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Daniel C Walsh
- Department of Neurovascular Surgery, King's College Hospital NHS Foundation Trust, London, UK
- Department of Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
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3
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Suzuki T, Kagawa K, Sato K, Nomura R, Irie K, Ichi S. CyberKnife Radiosurgery for Spinal Intramedullary Arteriovenous Malformations: A Single-Center Experience. World Neurosurg 2023; 175:e230-e237. [PMID: 36940806 DOI: 10.1016/j.wneu.2023.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Intramedullary spinal arteriovenous malformation (ISAVM, glomus type) is a type of spinal cord arteriovenous malformation, which is a rare disease known often to have a complex vascular supply interfering with that of the spinal cord, and is in complex anatomical relations with cord structures and nerve roots. Though microsurgical and endovascular treatment has mainly been the standard options, in high-risk cases with these treatments, stereotactic radiotherapy (SRT) might be the option of choice. METHODS We retrospectively reviewed 10 consecutive patients with ISAVM who received SRT using CyberKnife at the Japanese Red Cross Medical Center (Tokyo, Japan) from January 2011 to March 2022. RESULTS No case in this series suffered from hemorrhage after applying SRT. One case experienced neurological impairment 10 years after SRT, which we attributed to venous congestion due to the remaining lesion. No case of radiation myelopathy was observed in this series. In one case, the nidus volume reduction and loss of flow voids were obvious, though improvement in the neurological outcome was not apparent. No radiological changes were observed in the other 9 patients. CONCLUSIONS Even in lesions without radiological changes, no hemorrhagic events were observed for an average period of 4 years. SRT may be a feasible option in treating ISAVM, especially for lesions in which microsurgical resection and endovascular treatment are inapplicable. To ascertain the safety and efficacy of this approach, further studies with more patients and longer follow-up is required.
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Affiliation(s)
- Tomoya Suzuki
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Kenji Kagawa
- Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Kengo Sato
- Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | | | - Koreaki Irie
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan; Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Shunsuke Ichi
- Department of Neurosurgery, Japanese Red Cross Medical Center, Tokyo, Japan
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Mamaril-Davis J, Aguilar-Salinas P, Avila MJ, Dumont T, Avery MB. Recurrence Rates Following Treatment of Spinal Vascular Malformations: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 173:e250-e297. [PMID: 36787855 DOI: 10.1016/j.wneu.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Spinal vascular malformations (SVMs), including arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs), are a varied group of vascular lesions that can be subclassified according to localization, vascular structure, and hemodynamics. Early intervention is necessary to halt progression of disease and minimize irreversible dysfunction. We sought to characterize initial treatment success and recurrence rates following interventional treatment of various types of SVMs. METHODS A systematic review and meta-analysis were performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. SVMs were categorized into 4 groups: dural AVFs, perimedullary AVFs, intramedullary AVMs, and extradural-intradural AVMs (e.g., epidural, paraspinal). Initial occlusion, recurrence, and complication rates were compared using random-effects analysis. RESULTS There were 112 manuscripts included, with a total of 5626 patients with SVM. For treatment, 2735 patients underwent endovascular embolization, 2854 underwent surgical resection, and 37 underwent stereotactic radiosurgery. The initial treatment success and overall recurrence rates following surgical resection of all SVMs were 89.5% (95% CI: 80.5%-98.5%) and 2.3% (95% CI: 0.9%-3.7%), respectively. Those rates following endovascular embolization were 55.9% (95% CI: 30.3%-81.5%) and 27.7% (95% CI: 11.2%-44.2%), respectively. Higher rates of initial treatment success and lower rates of recurrence with surgery were observed in all subtypes compared to embolization. Overall complication rates were higher after embolization for each of the SVM categories. CONCLUSIONS Surgical resection of SVMs provided higher rates of initial complete occlusion and lower rates of recurrence than endovascular techniques. Attaining technical success through obliteration must still be weighed against clinical impact and natural history of the specific vascular malformation.
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Affiliation(s)
- James Mamaril-Davis
- College of Medicine, The University of Arizona College of Medicine - Tucson, Tucson, Arizona, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA
| | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA
| | - Travis Dumont
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA
| | - Michael B Avery
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA.
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Pacult MA, Spetzler RF. A Classification Proposal for Spinal Vascular Lesions. Neurosurgery 2023; 69:5-8. [PMID: 36924485 DOI: 10.1227/neu.0000000000002399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Mark A Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Baig Mirza A, Gebreyohanes A, Knight J, Bartram J, Vastani A, Kalaitzoglou D, Lavrador JP, Kailaya-Vasan A, Maratos E, Bell D, Thomas N, Gullan R, Malik I, Grahovac G. Prognostic factors for surgically managed intramedullary spinal cord tumours: a single-centre case series. Acta Neurochir (Wien) 2022; 164:2605-2622. [PMID: 35829775 DOI: 10.1007/s00701-022-05304-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/11/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE Intramedullary spinal cord tumours (IMSCTs) are comparatively rare neoplasms. We present a single-centre clinical case series of adult patients with surgically managed IMSCTs. METHODS We performed a retrospective analysis of electronic patient records in the time period spanning July 2010 to July 2021. All adult patients that had undergone surgical management for IMSCTs were eligible for inclusion. Baseline and post-operative clinical and radiological characteristics, along with follow-up data, were assessed. We also performed a literature review with a focus on surgical outcomes for IMSCTs. RESULTS Sixty-six patients matched our selection criteria, with a median age of 42 years (range 23-85). Thirty-four ependymomas, 17 haemangioblastomas, 12 astrocytomas, 2 lymphomas and 1 teratoma were included. Statistical analysis yielded several significant findings: IMSCTs spanning a greater number of vertebral levels are significantly associated with poor McCormick outcomes (p = 0.03), presence of gait disturbance before surgery is significantly associated with poor outcome for both post-operative McCormick and Nurick scores (p = 0.007), and radicular pain present pre-operatively is significantly associated with a good post-operative McCormick score (p = 0.045). Haemangioblastomas are significantly more likely to have a clear intra-operative dissection plane compared to ependymomas and astrocytomas (p = 0.009). However, astrocytomas have a significantly higher prevalence of good McCormick outcomes compared to ependymomas and haemangioblastomas (p = 0.03). CONCLUSION Histological diagnosis, cranio-caudal extent of the tumour and the presence or absence of baseline deficits-such as gait impairment and radicular pain-are significant in determining neurological outcomes after surgery for IMSCTs.
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Affiliation(s)
- Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK.
| | - Axumawi Gebreyohanes
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - James Knight
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - James Bartram
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Amisha Vastani
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Dimitrios Kalaitzoglou
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Jose Pedro Lavrador
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Ahilan Kailaya-Vasan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Eleni Maratos
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - David Bell
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Nick Thomas
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Richard Gullan
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Irfan Malik
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Gordan Grahovac
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
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Spinal Vascular Shunts: Single-Center Series and Review of the Literature of Their Classification. Neurol Int 2022; 14:581-599. [PMID: 35893282 PMCID: PMC9326594 DOI: 10.3390/neurolint14030047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Spinal arteriovenous shunts (sAVSs) are an uncommon disease, constituting 3 to 4% of intradural lesions; 70% of these lesions are spinal arteriovenous fistulas (sAVFs), whereas spinal arteriovenous malformations (sAVMs) are rarer. Both share the problem of their classification due to the heterogeneity of their angioarchitecture. The aim of this study is to report a series of sAVSs treated in the neurosurgery department of the Hospital Nacional Guillermo Almenara during the 2018–2020 period and to present an overview of the current literature on sAVS classification. We reviewed all medical records of patients diagnosed with sAVFs and sAVMs during the 2018–2020 period, and then we analyzed images with Horos v4.0.0, illustrated some cases with Clip Studio Paint v1.10.5, and performed a descriptive statistical analysis with SPSS v25. Twelve patients were included in this study, eight of which were women (67%) and four of which were men (33%); the age range was from 3 to 74 years. Eight sAVSs were sAVFs, whereas four were sAVMs. The most frequent clinical manifestation was chronic myelopathy in seven patients (58%). Of those treated only by embolization, seven (70%) resulted in complete occlusion (five sAVFs and two sAVMs), while three (30%) remained with a residual lesion. At last follow-up, five patients (42%) improved clinically, and the seven remaining (58%) maintained the same neurological state. sAVSs require a detailed study of their angioarchitecture for proper management. The endovascular treatment is safe with acceptable cure rates. The surgical option should not be set aside.
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Kona MP, Buch K, Singh J, Rohatgi S. Spinal Vascular Shunts: A Patterned Approach. AJNR Am J Neuroradiol 2021; 42:2110-2118. [PMID: 34649916 DOI: 10.3174/ajnr.a7312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/29/2021] [Indexed: 11/07/2022]
Abstract
Spinal vascular shunts, including fistulas and malformations, are rare and complex vascular lesions for which multiple classification schemes have been proposed. The most widely adopted scheme consists of 4 types: type I, dural AVFs; type II, intramedullary glomus AVMs; type III, juvenile/metameric AVMs; and type IV, intradural perimedullary AVFs. MR imaging and angiography techniques permit detailed assessment of spinal arteriovenous shunts, though DSA is the criterion standard for delineating vascular anatomy and treatment planning. Diagnosis is almost exclusively based on imaging, and features often mimic more common pathologies. The radiologist's recognition of spinal vascular shunts may improve outcomes because patients may benefit from early intervention.
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Affiliation(s)
- M P Kona
- From the Division of Neuroradiology (M.P.K.), Department of Radiology, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
| | - K Buch
- Division of Neuroradiology (K.B.), Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - J Singh
- Division of Neuroradiology (J.S., S.R.), Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - S Rohatgi
- Division of Neuroradiology (J.S., S.R.), Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
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Zhang K, Li C, Hou K, Yu J. Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend? Front Neurol 2021; 12:761006. [PMID: 34764934 PMCID: PMC8576071 DOI: 10.3389/fneur.2021.761006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.
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Affiliation(s)
- Kun Zhang
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou University, Zhengzhou, China
| | - Chao Li
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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Mizutani K, Consoli A, Maria FD, Condette Auliac S, Boulin A, Coskun O, Gratieux J, Rodesch G. Intradural spinal cord arteriovenous shunts in a personal series of 210 patients: novel classification with emphasis on anatomical disposition and angioarchitectonic distribution, related to spinal cord histogenetic units. J Neurosurg Spine 2021; 34:920-930. [PMID: 33799293 DOI: 10.3171/2020.9.spine201258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/15/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Few classifications of intradural spinal arteriovenous shunts (ID-SAVSs) have considered their anatomical localization in relation to their phenotype and angioarchitectonics. The authors propose another vision of ID-SAVSs allowing a reappraised classification based on analysis of the anatomical disposition, angioarchitecture, and histogenetic location of these vascular malformations. METHODS The radiological and clinical records of 210 patients with ID-SAVSs were retrospectively reviewed, considering their localization, vascular architectonics, and correlation with the 5 histogenetic units of the spinal cord. Among these, 183 files with complete data allowed precise analysis of the ID-SAVSs. RESULTS Among these 183 files (162 and 21 cases with single and multiple lesions, respectively), different entities were identified: 13 pial macro arteriovenous fistulas (MAVFs), 92 pial micro arteriovenous fistulas (mAVFs), 33 superficial pial niduses, and 69 intramedullary niduses. Thirteen sulcal shunts (either fistulas or niduses) were considered subtypes of pial lesions. Among the 21 multiple cases, 11 were monomyelomeric while 10 were multimyelomeric. Pial lesions, either fistulas or niduses, were dominantly vascularized by pial arteries (anterior or posterior depending on the localization of the shunt) and occasionally (except for MAVFs) by transmedullary arteries. Pial niduses occasionally extended into the funiculus by recruiting intrinsic veins or by extension of the nidus itself inside the white matter. Intramedullary niduses were always vascularized by both centrifugal and centripetal feeders, respectively, from sulcal arteries (SAs) and pial arteries. Sulcal lesions are pial lesions located within the ventral median sulcus and vascularized by SAs and veins. Single or multiple ID-SAVSs can be part of various syndromes such as hereditary hemorrhagic telangiectasia, Parkes-Weber, RASA1, CLOVES, and spinal arteriovenous metameric syndromes. Histogenetic analyses revealed a specific distribution of each ID-SAVS in the 5 histogenetic units of the spinal cord: intramedullary niduses were found almost equally from cervical to thoracic units, while MAVFs and mAVFs were mostly found from thoracic to postcrural ones. Pial niduses showed intermediate features between intramedullary and fistulous lesions and were mostly distributed from brachial to crural segments. CONCLUSIONS Precise analysis of the anatomical disposition of ID-SAVSs in relation to functional histogenetic units allows a better understanding of these lesions and improved therapeutic management.
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Affiliation(s)
- Katsuhiro Mizutani
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
- 2Department of Neurosurgery, Keio University School of Medicine, Shinjuku, Tokyo; and
- 3Department of Neurosurgery, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan
| | - Arturo Consoli
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Federico Di Maria
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Stéphanie Condette Auliac
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Anne Boulin
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Oguzhan Coskun
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Julie Gratieux
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
| | - Georges Rodesch
- 1Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, Hauts-de-Seine, France
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11
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Consoli A, Coskun O, Di Maria F, Gratieux J, Condette-Auliac S, Smadja S, Boulin A, Rodesch G. Spinal cord arterio-venous shunts: From classification to therapeutic management. Rev Neurol (Paris) 2021; 177:469-476. [PMID: 33781564 DOI: 10.1016/j.neurol.2021.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/24/2022]
Abstract
Spinal Cord Arterio-Venous shunts (SCAVSs) are a rare disease. The aim of this paper is to describe how we classify and consider management of SCAVSs in relation to the location of the shunt focusing mainly on intradural SCAVSs. The anatomical features of the SCAVSs together with data provided by MRI and CT scans allow identification of four types of SCAVSs: paraspinal, epidural, dural and intradural ones. Clinical and neuroradiologic characteristics are described for each entity as well as the therapeutic endovascular management at our institution between 2002 and 2020. The therapeutic management of SCAVSs, and in particular of intradural shunts, remains mainly based on endovascular treatment as a first-choice approach. Understanding properly the lesional and regional vascular anatomy is mandatory to plan an appropriate therapeutic strategy and obtain good clinical results stable at long term follow up.
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Affiliation(s)
- A Consoli
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France.
| | - O Coskun
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - F Di Maria
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - J Gratieux
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - S Condette-Auliac
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - S Smadja
- Interventional Neuroradiology, Fondation Rotschild Hospital, 29, rue Manin, 75019 Paris, France
| | - A Boulin
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
| | - G Rodesch
- Diagnostic and interventional neuroradiology, hôpital FOCH, Constitutive Reference Center for Rare Diseases - Spinal Cord Arteriovenous Malformations, Avance Network, "FAVA Multi" Sector, 40, rue Worth, 92151 Suresnes, France
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Tominaga S, Kugai M, Matsuda K, Yamazato K, Inui T, Kitano M, Hasegawa H. Usefulness of the middle cerebellar peduncle approach for microsurgical resection of lateral pontine arteriovenous malformation. NEUROSURGICAL FOCUS: VIDEO 2021; 4:V11. [PMID: 36284622 PMCID: PMC9542488 DOI: 10.3171/2020.10.focvid2063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/15/2020] [Indexed: 12/02/2022]
Abstract
Surgical treatment of brainstem arteriovenous malformation (AVM) is challenging and associated with a higher risk of complications and a lower rate of gross-total resection. The authors present their experience with the surgical management of lateral pontine AVM using the middle cerebellar peduncle approach. All cases presented with neurological deficits that were caused by hemorrhage before surgery. In all cases, the AVM was not visualized on postoperative angiography, and there was no deterioration of neurological symptoms. In this video, the authors report the treatment results of one case and describe the technique with a review of the literature. The video can be found here: https://youtu.be/bFvEMtMnrKw
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Microsurgical or endovascular strategy for complete obliteration of spinal arteriovenous shunts in a single-institute 10-year retrospective study. J Clin Neurosci 2020; 80:195-202. [PMID: 33099345 DOI: 10.1016/j.jocn.2020.08.015] [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: 05/10/2020] [Revised: 08/02/2020] [Accepted: 08/09/2020] [Indexed: 11/24/2022]
Abstract
The objective of this retrospective study is to more fully understand the optimal strategy to manage spinal arteriovenous (AV) shunts. This study included a cohort of 35 patients with a diagnosis of spinal AV shunts who were treated over the past 10 years at a single institute. Angiographic diagnosis of intramedullary AV malformations (IM-AVM), perimedullary AV fistulas (PM-AVF), dural AV fistulas (D-AVF), or epidural AV fistulas (ED-AVF) was carefully made, and the microsurgical or endovascular strategy for them was determined at the interdisciplinary meeting consisting of neurospinal surgeons and endovascular specialists. Endovascular surgery was first considered whenever safely possible. Microscopic direct surgery using intraoperative image guidance was considered for cases in which endovascular access was challenging or not safely possible. Combined treatment was another option. The clinical condition was assessed using the modified Rankin scale (mRS). Seventeen of 35 cases were treated with microscopic direct surgery, 13 cases with endovascular surgery, and the remaining five cases with the combination. Complete angiographic obliteration was achieved in 30 of 35 cases (85.7%). Although residual AV shunts was recognized in 3 cases of IM-AVM, 1 case of PM-AVF and 1 case of ED-AVF, no angiographic recurrence was present with an average postoperative follow-up period of 44 months. The average mRS before surgery was 2.37 and significantly improved to 1.94 at the most recent follow-up. Interdisciplinary collaboration between neurospinal surgeons and endovascular specialists should be standard to achieve safe and successful outcomes in treating such rare and difficult spinal disorders.
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Cohen-Gadol A. Challenging Dogma in Arteriovenous Malformation Surgery: Personal Reflections and Lessons Learned from 350 Cases. World Neurosurg 2020; 139:83-89. [DOI: 10.1016/j.wneu.2020.01.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/24/2022]
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15
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Eichberg DG, Komotar RJ, Urakov TM. Commentary: Spinal Arteriovenous Fistula: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E227-E228. [PMID: 32243536 DOI: 10.1093/ons/opaa063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Timur M Urakov
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Brinjikji W, Colombo E, Lanzino G. Clinical and angioarchitectural characteristics of spinal vascular malformations of the cervical spine. J Neurosurg Spine 2020; 32:755-762. [PMID: 31952038 DOI: 10.3171/2019.11.spine19798] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Vascular malformations of the cervical spine are exceedingly rare. To date there have been no large case series describing the clinical presentation and angioarchitectural characteristics of cervical spine vascular malformations. The authors report their institutional case series on cervical spine vascular malformations diagnosed and treated at their institution. METHODS The authors retrospectively reviewed all patients with spinal vascular malformations from their institution from January 2001 to December 2018. Patients with vascular malformations of the cervical spine were included. Lesions were characterized by their angioarchitectural characteristics by an interventional neuroradiologist and endovascular neurosurgeon. Data were collected on clinical presentation, imaging findings, treatment outcomes, and long-term follow-up. Descriptive statistics are reported. RESULTS Of a total of 213 patients with spinal vascular malformations, 27 (12.7%) had vascular malformations in the cervical spine. The mean patient age was 46.1 ± 21.9 years and 16 (59.3%) were male. The most common presentations were lower-extremity weakness (13 patients, 48.1%), tetraparesis (8 patients, 29.6%), and lower-extremity sensory dysfunction (7 patients, 25.9%). Nine patients (33.3%) presented with hemorrhage. Fifteen patients (55.6%) had modified Rankin Scale scores of 0-2 at the time of diagnosis. Regarding angioarchitectural characteristics, 8 patients (29.6%) had intramedullary arteriovenous malformations (AVMs), 5 (18.5%) had epidural arteriovenous fistulas (AVFs), 4 (14.8%) had paraspinal fistulas, 4 (14.8%) had mixed epidural/intradural fistulas, 3 (11.1%) had perimedullary AVMs, 2 (7.4%) had dural fistulas, and 1 patient (3.7%) had a perimedullary AVF. CONCLUSIONS This retrospective study of 27 patients with cervical spine vascular malformations is the largest series to date on these lesions. The authors found substantial angioarchitectural heterogeneity with the most common types being intramedullary AVMs followed by epidural AVFs, paraspinal fistulas, and mixed intradural/extradural fistulas. Angioarchitecture dictated the clinical presentation as intradural shunts were more likely to present with hemorrhage and acute onset myelopathy, while dural and extradural shunts presented as either incidental lesions or gradually progressive congestive myelopathy.
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Affiliation(s)
- Waleed Brinjikji
- Departments of1Neurosurgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Giuseppe Lanzino
- Departments of1Neurosurgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
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17
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Eichberg DG, Komotar RJ, Urakov TM. Commentary: Posterior C2-6 Laminoplasty for Resection of Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E140-E141. [PMID: 32047933 DOI: 10.1093/ons/opaa006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/15/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Daniel G Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Timur M Urakov
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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18
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Brinjikji W, Ahn ES, Patterson MC, Lanzino G. Challenging dogma: report of a spinal cord arteriovenous malformation as an acquired lesion in a pediatric patient. J Neurosurg Spine 2020; 32:302-304. [PMID: 31653811 DOI: 10.3171/2019.7.spine19253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/12/2019] [Indexed: 11/06/2022]
Abstract
Spinal cord intramedullary arteriovenous malformations (AVMs) have classically been considered congenital lesions that are present from birth. The reason for this dogmatic principal is the fact that a vast majority of these lesions present in pediatric and young adult patients. Interestingly, while many authors have demonstrated the development of de novo nidus-type brain AVMs, there have been no reported cases of a de novo intramedullary or perimedullary AVM of the spine. In this paper the authors describe what they believe to be the first reported case of a de novo AVM of the spinal cord in a young patient who underwent serial imaging from birth for evaluation of a syrinx. Potential pathophysiological mechanisms for the development of de novo vascular malformations of the spinal cord are discussed.
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Adult Spinal Arteriovenous Malformations: Natural History and a Multicenter Study of Short-Term Surgical Outcomes. World Neurosurg 2019; 132:e290-e296. [PMID: 31479792 DOI: 10.1016/j.wneu.2019.08.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Spinal arteriovenous malformations (SAVMs) are a very rare and complex spinal cord pathology that require high clinical acumen to diagnose and treat. Management includes both nonoperative and operative paradigms. A review of the literature yields a paucity of data regarding the surgical outcomes of SAVMs, with the majority of data limited to single-center outcomes and/or small sample sizes. The purpose of this study was to use a multi-institutional international database to study the natural history of SAVMs. METHODS We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to select patients that underwent laminectomy for surgical excision of a SAVM between 2008 and 2017. RESULTS The data from 196 patients were studied (65.8% male, 34.2% female). A majority of cases were in the thoracic region (53.6%), followed by thoracolumbar (31.6%) and cervical (14.8%) regions. The mean age was 57.4 years and 52.5% patients were graded ASA class 3-5 before the operation. The mean operation time was 215 minutes, with a significantly lower operative time for thoracic arteriovenous malformations (195.6 minutes) when compared with cervical (266.6 minutes) and thoracolumbar (223.7 minutes). The mean length of hospital stay was 6.4 days. Patients had a 6.6% readmission rate and a 4.6% reoperation rate within 30 days. CONCLUSIONS This study presents the largest analysis of patients undergoing surgery for SAVMs and 30-day postoperative outcomes. Operative time differed based on SAVM location. The three most frequent complications (deep vein thrombosis, wound infection, and UTI) occurred at rates of 3.6% or less.
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20
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Lenck S, Nicholson P, Tymianski R, Hilditch C, Nouet A, Patel K, Krings T, Tymianski M, Radovanovic I, Mendes Pereira V. Spinal and Paraspinal Arteriovenous Lesions. Stroke 2019; 50:2259-2269. [DOI: 10.1161/strokeaha.118.012783] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Stéphanie Lenck
- From the Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and University of Toronto (S.L., P.N., C.H., T.K., V.M.P.), University Health Network, ON, Canada
- Division of Neuroradiology (S.L.), Groupe Hospitalier Pitié-Salpêtrière, Paris Sorbonne University, France
| | - Patrick Nicholson
- From the Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and University of Toronto (S.L., P.N., C.H., T.K., V.M.P.), University Health Network, ON, Canada
| | - Rachel Tymianski
- Adelaide Medical School, University of Adelaide, Australia (R.T.)
| | - Christopher Hilditch
- From the Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and University of Toronto (S.L., P.N., C.H., T.K., V.M.P.), University Health Network, ON, Canada
| | - Aurélien Nouet
- Division of Neurosurgery (A.N.), Groupe Hospitalier Pitié-Salpêtrière, Paris Sorbonne University, France
| | - Krunal Patel
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada (K.P., M.T., I.R., V.M.P.)
| | - Timo Krings
- From the Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and University of Toronto (S.L., P.N., C.H., T.K., V.M.P.), University Health Network, ON, Canada
| | - Michael Tymianski
- Krembil Neuroscience Center (M.T., I.R.), University Health Network, ON, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada (K.P., M.T., I.R., V.M.P.)
| | - Ivan Radovanovic
- Krembil Neuroscience Center (M.T., I.R.), University Health Network, ON, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada (K.P., M.T., I.R., V.M.P.)
| | - Vitor Mendes Pereira
- From the Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and University of Toronto (S.L., P.N., C.H., T.K., V.M.P.), University Health Network, ON, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, ON, Canada (K.P., M.T., I.R., V.M.P.)
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21
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Hu SY, Chen WH, Huang JA. Acute urinary retention associated with spinal arteriovenous malformation. Br J Hosp Med (Lond) 2019; 80:iii. [DOI: 10.12968/hmed.2019.80.3.iii] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sung-Yuan Hu
- Consultant, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan, and School and Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Wen-Hsien Chen
- Consultant, Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jin-An Huang
- Consultant, Neurology Center, Taichung Veterans General Hospital, Taichung, Taiwan
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22
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Jing L, Su W, Guo Y, Sun Z, Wang J, Wang G. Microsurgical treatment and outcomes of spinal arteriovenous lesions: Learned from consecutive series of 105 lesions. J Clin Neurosci 2017; 46:141-147. [PMID: 28986150 DOI: 10.1016/j.jocn.2017.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 09/05/2017] [Accepted: 09/11/2017] [Indexed: 11/18/2022]
Abstract
Spinal arteriovenous lesions (SAVLs), arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs), are rare and can devastatingly impair spinal cord function. This study aimed to evaluate clinical outcomes after microsurgical treatment with the aid of intraoperative indocyanine green video-angiography (ICG-VA) in a large series of patients with SAVLs. We retrospectively reviewed the cases of 95 consecutive patients with 105 SAVLs (77 spinal AVFs, 28 spinal AVMs) who had been treated surgically during 2010-2016 in two hospitals by the same experienced surgeon. All patients had undergone magnetic resonance imaging and digital subtraction angiography preoperatively and were assessed using the modified Aminoff and Logue Scale (mALS). All lesions were resected or occluded using ICG-VA. No ICG-VA-related complications occurred. Compared with AVF, patients with AVM tended to be younger (p<0.001) and were at higher risk of an associated aneurysm (p=0.021), hemorrhage (p<0.001), pain (p<0.001) and abrupt onset (p<0.001). SAVLs were most common in the lower thoracic region (45.71%), and their most common clinical presentation was paresthesia (89.52%). At a mean follow-up of 33.3months, mALS indicated significant improvement in patients with spinal AVFs (p<0.001) and AVMs (p=0.002) compared with their status preoperatively. An improved, stable clinical status was noted at the last follow-up in 93.51% of those with AVFs and 89.28% of those with AVMs. Thus, microsurgical treatment of SAVLs produced a lasting positive clinical outcome in a large cohort of consecutive patients. ICG-VA proved to be an efficient intraoperative tool during resection of these lesions, especially in patients with an AVF.
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Affiliation(s)
- Linkai Jing
- School of Clinical Medicine, Tsinghua University, Beijing 100084, China; Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Wei Su
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China; Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Yi Guo
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Zhenxing Sun
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - James Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Guihuai Wang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China; Department of Neurosurgery, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China.
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Lagman C, Chung LK, Chitale RV, Yang I. Dural Arteriovenous Fistula and Foix-Alajouanine Syndrome: Assessment of Functional Scores with Review of Pathogenesis. World Neurosurg 2017; 106:206-210. [DOI: 10.1016/j.wneu.2017.06.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 12/16/2022]
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Ozpinar A, Weiner GM, Ducruet AF. Epidemiology, clinical presentation, diagnostic evaluation, and prognosis of spinal arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:145-152. [PMID: 28552136 DOI: 10.1016/b978-0-444-63640-9.00014-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Spinal arteriovenous malformations (sAVM) are rare vascular pathologies whose natural history remains incompletely understood. Advances in diagnostic imaging, coupled with the evolution of endovascular and microsurgical techniques have led to the description of a number of classification schemes for these lesions. An updated method has changed AVM classification from five categories of lesion based on source and location of feeder vessels to three categories based on pathophysiology. These categories include extradural arteriovenous fistulae (AVFs), intradural AVFs, extradural-intradural AVFs, intramedullary AVMs, and conus medullaris AVM each with individual subclassifications. Treatment outcomes have been shown to differ based on classification criteria. The increased use of advanced imaging prior to surgical intervention has facilitated the treatment of AVFs. Definitive diagnosis and characterization have traditionally required digital subtraction angiography, which is now being supplemented with other forms of noninvasive imaging such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Epidemiologically, intradural dorsal AVFs account for 80% of all sAVMs, and are characterized by low-pressure shunts located in the sleeve of the dorsal nerve root. Microsurgical treatment has been shown to be highly effective in cases of intradural dorsal AVFs, although many cases are also amenable to durable occlusion using liquid embolics. Conus medullaris AVMs, which has only been recently characterized as a separate category of sAVM, is best treated using a combination of embolization and microsurgery. Successful treatment of sAVM mandates a thorough understanding of the anatomy and classification of these lesions. The purpose of this chapter is to review and summarize the classification, natural history, and prognosis of sAVMs.
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Affiliation(s)
- Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gregory M Weiner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew F Ducruet
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Xu DS, Sun H, Spetzler RF. Spinal arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:153-160. [DOI: 10.1016/b978-0-444-63640-9.00015-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Daou B, Atallah E, Al-Saiegh F, Alkhalili K, Tjoumakaris S, Rosenwasser RH, Jabbour P. Spinal Glomus Arteriovenous Malformation Manifesting with a Subarachnoid Hemorrhage. World Neurosurg 2016; 98:874.e1-874.e6. [PMID: 27923749 DOI: 10.1016/j.wneu.2016.11.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/22/2016] [Accepted: 11/23/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Spinal arteriovenous malformations (AVMs) are rare lesions that may cause serious neurologic morbidity. With developments in endovascular technology and embolic materials, endovascular management of spinal AVMs has gained popularity. CASE DESCRIPTION A 61-year-old woman presented with the worst headache of her life and an acute onset of nausea and vomiting and was shown to have a grade 2 subarachnoid hemorrhage (SAH) on computed tomography scan. A 6-vessel cerebral angiogram was negative for any vascular abnormalities. Magnetic resonance imaging and magnetic resonance angiography of the neck showed a flow-related enhancement compatible with a vascular abnormality at the level of C2. Cervical spinal angiography showed a cervical spinal cord glomus (type II) AVM at the level of C2 draining into perimedullary venous plexus. Transarterial Onyx embolization was performed and resulted in complete occlusion of the AVM. The patient made a complete neurologic recovery. CONCLUSIONS Spinal AVMs manifesting as intracranial SAH are uncommon. These lesions are frequently overlooked on cerebral angiography and account for a small proportion of angiogram-negative SAHs. A negative angiogram in the setting of SAH should prompt a comprehensive evaluation of the cervical segmental arterial supply to exclude a cervical spinal AVM. Endovascular embolization may be effective in treating spinal glomus AVMs with good clinical outcomes and with complete angiographic obliteration. Onyx embolic agent should be considered as the agent of choice to manage spinal glomus AVMs.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Fadi Al-Saiegh
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Kenan Alkhalili
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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Ye ZP, Yang XY, Li WS, Hou B, Guo Y. Microsurgical Resection of Cervical Spinal Cord Arteriovenous Malformations: Report of 6 Cases. World Neurosurg 2016; 96:362-369. [PMID: 27641254 DOI: 10.1016/j.wneu.2016.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 09/01/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To summarize the experience in microsurgical resection of cervical spinal cord arteriovenous malformation (AVM). METHODS Six patients undergoing microsurgical resection of cervical intramedullary AVM in the Third Affiliated Hospital of Sun Yat-sen University, China, between March 2005 and March 2015 were reviewed retrospectively, and their clinical manifestations, imaging data, surgical treatment, and results of long-term follow-up were analyzed. RESULTS Of the 6 patients who underwent AVM resection, 2 had compact AVMs and 4 had diffuse AVMs. All 6 patients were reexamined with spinal magnetic resonance imaging within 48 hours after surgery, and 1 patient was examined with digital subtraction angiography. The average patient age was 40.7 ± 10.4 years (range, 29-60 years). Three patients had chronic onset, of whom 2 developed sensory disturbances and 1 had muscle weakness. The other 3 patients had acute onset, including 1 with sudden quadriplegia, 1 with idiopathic severe headache and altered consciousness, and 1 with idiopathic neck pain. The average duration of follow-up was 48.5 ± 38.9 months (range, 15-119 months). One patient experienced complete recovery, and the other 5 patients showed improvement. No patient exhibited deterioration. CONCLUSION Microsurgical resection of cervical intramedullary AVMs has obtained satisfactory clinical results. Preoperative magnetic resonance angiography, computed tomography angiography, and digital subtraction angiography are useful for evaluating the angioarchitecture, which is key to the success of surgery. Intraoperative indocyanine green fluorescence angiography is an important aid in the surgical treatment of spinal AVMs.
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Affiliation(s)
- Zhuo-Peng Ye
- Department of Neurosurgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-Yan Yang
- Department of Emergency Medicine, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wen-Shen Li
- Department of Neurosurgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bo Hou
- Department of Neurosurgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Guo
- Department of Neurosurgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Kalani MA, Choudhri O, Gibbs IC, Soltys SG, Adler JR, Thompson PA, Tayag AT, Samos CH, Chang SD. Stereotactic radiosurgery for intramedullary spinal arteriovenous malformations. J Clin Neurosci 2016; 29:162-7. [DOI: 10.1016/j.jocn.2015.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 12/05/2015] [Indexed: 10/22/2022]
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Rashad S, Endo T, Ogawa Y, Sato K, Endo H, Matsumoto Y, Takahashi A, Tominaga T. Stereotactic radiosurgery as a feasible treatment for intramedullary spinal arteriovenous malformations: a single-center observation. Neurosurg Rev 2016; 40:259-266. [PMID: 27270299 DOI: 10.1007/s10143-016-0758-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 11/29/2022]
Abstract
Spinal cord intramedullary arteriovenous malformations are rare. For patients suffering from either hemorrhage or myelopathy, surgical or endovascular interventions are indicated. However, complete eradication of the nidus is often difficult because of its intramedullary location and complex angioarchitecture. In this report, we evaluate the feasibility and safety of stereotactic radiosurgery as a treatment modality for intramedullary spinal arteriovenous malformations (AVMs). Between 2010 and 2014, we performed stereotactic radiosurgery to treat four patients with intramedullary AVM and one with spinal arteriovenous metameric syndrome (one woman and four men; age range, 31-66 years). Three patients presented with myelopathy, and two suffered hemorrhages. Nidi were located in the cervical (three cases) and thoracic (two cases) spinal cord regions. Based on the angioarchitecture, surgery and endovascular embolization were indicated. When both modalities were deemed hazardous, radiosurgery using CyberKnife™ was offered. Radiation using marginal doses of 18 Gy was administered in three fractions. The mean follow-up period was 37.2 months (range, 16-62 months). After treatment, two of the three patients with myelopathy experienced either improvement or stabilization of their symptoms and one experienced worsening of dysesthesia. In two patients with hemorrhage, symptoms improved in one and remained stable in the other. No further hemorrhagic episodes were evident during follow-up. Follow-up angiograms showed marked shrinkage of the nidus located in the thoracic spinal cord in one case and angiographic stabilization in the others. As a treatment modality for intramedullary AVMs, CyberKnife™ is safe and can be considered when surgery or endovascular therapy is not indicated. To determine optimum radiation doses and protocols for treating spinal AVMs, further studies with more patients and long-term follow-up are required.
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Affiliation(s)
- Sherif Rashad
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, 980-8574, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, 980-8574, Japan.
| | | | - Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Hidenori Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, 980-8574, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Akira Takahashi
- Department of Neuroendovascular Therapy, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, 980-8574, Japan
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Flores BC, Klinger DR, White JA, Batjer HH. Spinal vascular malformations: treatment strategies and outcome. Neurosurg Rev 2016; 40:15-28. [DOI: 10.1007/s10143-016-0713-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 11/05/2015] [Accepted: 01/25/2016] [Indexed: 12/16/2022]
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Singh B, Behari S, Jaiswal AK, Sahu RN, Mehrotra A, Mohan BM, Phadke RV. Spinal arteriovenous malformations: Is surgery indicated? Asian J Neurosurg 2016; 11:134-42. [PMID: 27057219 PMCID: PMC4802934 DOI: 10.4103/1793-5482.177663] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: To identify clinico-radiological distinguishing features in various types of spinal arteriovenous malformations (AVM) with an aim to define the role of surgical intervention. Materials and Methods: Hero's modified Di Chiro classification differentiated four types of spinal AVMs on digital subtraction angiogram (DSA) in 74 patients: I. Dural arteriovenous fistulae (n = 35, 47.3%); II. Glomus/intramedullary (n = 13, 17.6%); III. Juvenile/metameric (n = 4, 5.4%); and, IV. Ventral perimedullary fistula (n = 21, 28.4%). A patient with extradural AVM remained unclassified. Demographic profiles, DSA features and reason for surgical referral were recorded. Statistical comparison of discrete variables like gender, spinal cord level, presentation and outcome was made using Chi-square test; and, continuous variables like age, feeder number, duration of symptoms and number of staged embolizations by one way analysis of variance with Boneferoni post hoc comparison. Embolization alone (n = 39, 52.7%), surgery alone (n = 16, 21.6%), and combined approach (n = 4, 5.4%) were the treatments offered (15 were treated elsewhere). Results: Type I-AVM occurred in significantly older population than other types (P = 0.01). Mean duration of symptoms was 13.18 ± 12.8 months. Thoracic cord involvement predominated in type-I and III AVMs (P = 0.01). Number of feeding arteries were 1 in 59.7%; 2 in 29.0%; and, multiple in 11.3% patients, respectively. Staged embolization procedures in type-III AVM were significant (P < 0.01). Surgical referral was required due to: Vessel tortuosity/insufficient parent vessel caliber (n = 7); residual AVM (n = 4); low flow AVM (n = 3); and, multiple feeders (n = 2). Check DSA (n = 34) revealed complete AVM obliteration in 26 and minor residual lesion in eight patients. Neurological status improved in 26 and stabilized in 25 patients. Conclusions: Differentiating between Type I-IV AVMs has a significant bearing on their management. Surgical intervention should be considered as an important adjunct/alternative to therapeutic embolization.
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Affiliation(s)
- Bikramjit Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - B Madan Mohan
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rajendra V Phadke
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Takai K, Taniguchi M. Microsurgical resection of an intramedullary glomus arteriovenous malformation in the high cervical spinal cord: retrograde dissection techniques of the nidus located between spinal tracts. Acta Neurochir (Wien) 2015; 157:1659-64. [PMID: 26276470 DOI: 10.1007/s00701-015-2531-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 07/30/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spinal intramedullary arteriovenous malformations (AVMs) fed by an anterior spinal artery are surgically challenging vascular lesions. METHOD We herein presented microsurgical resection techniques for an intramedullary glomus AVM located in the lateral part of the high cervical spinal cord with an operative video. These techniques included (1) a lateral suboccipital approach via cervical hemilaminectomy in the lateral position; (2) retrograde dissection of the AVM located between the spinal tracts; (3) coagulation and division of multiple narrow sulcal branches of the anterior spinal artery. CONCLUSION Patients who underwent these techniques achieved good outcomes with minimal bleeding and morbidity.
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Affiliation(s)
- Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo, 183-0042, Japan.
| | - Makoto Taniguchi
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo, 183-0042, Japan
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Tucker A, Tsuji M, Yamada Y, Hanabusa K, Ukita T, Miyake H, Ohmura T. Arteriovenous malformation of the vestibulocochlear nerve. World J Clin Cases 2015; 3:661-670. [PMID: 26244159 PMCID: PMC4517342 DOI: 10.12998/wjcc.v3.i7.661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/14/2014] [Accepted: 04/20/2015] [Indexed: 02/05/2023] Open
Abstract
We describe a rare case of an arteriovenous malformation (AVM) embedded in the vestibulocochlear nerve presenting with subarachnoid hemorrhage (SAH) treated by microsurgical elimination of the main feeding artery and partial nidus volume reduction with no permanent deficits. This 70-year-old woman was incidentally diagnosed 4 years previously with two small unruptured tandem aneurysms (ANs) on the right anterior inferior cerebral artery feeding a small right cerebellopontine angle AVM. The patient was followed conservatively until she developed sudden headache, nausea and vomiting and presented to our outpatient clinic after several days. Magnetic resonance imaging demonstrated findings suggestive of early subacute SAH in the quadrigeminal cistern. A microsurgical flow reduction technique via clipping between the two ANs and partial electrocoagulation of the nidus buried within the eighth cranial nerve provided radiographical devascularization of the ANs with residual AVM shunt flow and no major deficits during the 2.5 year follow-up. This is only the second report of an auditory nerve AVM. In the event of recurrence, reoperation or application of alternative therapies may be considered.
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Han SJ, Englot DJ, Kim H, Lawton MT. Brainstem arteriovenous malformations: anatomical subtypes, assessment of "occlusion in situ" technique, and microsurgical results. J Neurosurg 2015; 122:107-17. [PMID: 25343188 DOI: 10.3171/2014.8.jns1483] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The surgical management of brainstem arteriovenous malformations (AVMs) might benefit from the definition of anatomical subtypes and refinements of resection techniques. Many brainstem AVMs sit extrinsically on pia mater rather than intrinsically in the parenchyma, allowing treatment by occluding feeding arteries circumferentially, interrupting draining veins after arteriovenous shunting is eliminated, and leaving the obliterated nidus behind. The authors report here the largest series of brainstem AVMs to define 6 subtypes, assess this "occlusion in situ" technique, and analyze the microsurgical results. METHODS Brainstem AVMs were categorized as 1 of 6 types: anterior midbrain, posterior midbrain, anterior pontine, lateral pontine, anterior medullary, and lateral medullary AVMs. Data from a prospectively maintained AVM registry were reviewed to evaluate multidisciplinary treatment results. RESULTS During a 15-year period, the authors treated 29 patients with brainstem AVMs located in the midbrain (1 anterior and 6 posterior), pons (6 anterior and 7 lateral), and medulla (1 anterior and 8 lateral). The nidus was pial in 26 cases and parenchymal in 3 cases. Twenty-three patients (79%) presented with hemorrhage. Brainstem AVMs were either resected (18 patients, 62%) or occluded in situ (11 patients, 38%). All lateral pontine AVMs were resected, and the occlusion in situ rate was highest with anterior pontine AVMs (83%). Angiography confirmed complete obliteration in 26 patients (89.6%). The surgical mortality rate was 6.9%, and the rate of permanent neurological deterioration was 13.8%. At follow-up (mean 1.3 years), good outcomes (modified Rankin Scale [mRS] score ≤ 2) were observed in 18 patients (66.7%) and poor outcomes (mRS score of 3-5) were observed in 9 patients (33.3%). The mRS scores in 21 patients (77.8%) were unchanged or improved. The best outcomes were observed with lateral pontine (100%) and lateral medullary (75%) AVMs, and the rate of worsening/death was greatest with posterior midbrain and anterior pontine AVMs (50% each). CONCLUSIONS Brainstem AVMs can be differentiated by their location in the brainstem (midbrain, pons, or medulla) and the surface on which they are based (anterior, posterior, or lateral). Anatomical subtypes can help the neurosurgeon determine how to advise patients, with lateral subtypes being a favorable surgical indication along with extrinsic pial location and hemorrhagic presentation. Most AVMs are dissected with the intention to resect them, and occlusion in situ is reserved for those AVMs that do not separate cleanly from the brainstem, that penetrate into the parenchyma, or are more anterior in location, where it is difficult to visualize and preserve perforating arteries (anterior pontine and lateral medullary AVMs). Although surgical morbidity is considerable, surgery results in a better obliteration rate than nonoperative management and is indicated in highly selected patients with high rerupture risks.
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Concomitant intramedullary arteriovenous malformation and a vertebral hemangioma of cervical spine discovered by a pathologic fracture during bicycle accident. 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 2014; 24:187-92. [PMID: 25351839 DOI: 10.1007/s00586-014-3620-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 10/06/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Spinal intramedullary arteriovenous malformations are uncommon and a challenging type of neurosurgical entities. They are rarely located to cervical segment. On the other hand, although hemangiomas are relatively common bone tumors, cervical involvement is again rare and clinically significant ones are infrequent. CASE PRESENTATION A 14 year-old-male patient referred to an academic tertiary care unit and presented with neck pain and left hand weakness. Neurological examination revealed motor strength deficit at intrinsic muscles and hyperesthesia at the left hand. Furthermore the pathological reflexes were positive on the left hand side. Imaging studies showed compression fracture, lytic changes resembling a hemangioma at C7 vertebra, and also an intramedullary vascular pathology at C5-6 level which was shown to be an intradural-intramedullary arteriovenous malformation (AVM) on digital subtraction angiography. Based on neurological and radiological findings, the decision was to treat the patient. After embolization of the AVM, the neurological condition of the patient deteriorated and immediate MRI scan of the cervical spine revealed edema of the spinal cord at the C5-6 level. Thus an emergent surgery was performed and C5-6-7 laminectomies with C5-T2 posterior fixation and arthrodesis were implemented. A second stage operation was carried out as C7 corpectomy with a distractable titanium cage 2 weeks after initial surgery. A follow-up evaluation at five years revealed 4/5 motor strength on his left intrinsic hand muscles and mild hyperactive deep tendon reflexes. Imaging studies at the postoperative period showed stable placement of the construct and no evidence of contrast enhancement at the C5-6 level inside the spinal cord. CONCLUSION A rare case of multiple pathologies affecting the cervical spine, coincidentally diagnosed after a pathological fracture during a bicycle accident as vertebral hemangioma and intradural-intramedullary AVM that was successfully treated with early detection, have been presented. One should assess such patients under multidisciplinary fashion and treat on a case-by-case basis for achieving the best results in patient care.
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Rangel-Castilla L, Russin JJ, Zaidi HA, Martinez-del-Campo E, Park MS, Albuquerque FC, McDougall CG, Nakaji P, Spetzler RF. Contemporary management of spinal AVFs and AVMs: lessons learned from 110 cases. Neurosurg Focus 2014; 37:E14. [DOI: 10.3171/2014.7.focus14236] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Object
Spinal arteriovenous fistulas (AVFs) and arteriovenous malformations (AVMs) are rare, complex spinal vascular lesions that are challenging to manage. Recently, understanding of these lesions has increased thanks to neuroimaging technology. Published reports of surgical results and clinical outcome are limited to small series. The authors present a large contemporary series of patients with spinal AVFs and AVMs who were treated at Barrow Neurological Institute in Phoenix, Arizona.
Methods
Retrospective detailed review of a prospective vascular database was performed for all patients with spinal AVFs and AVMs treated between 2000 and 2013. Patient demographic data, AVF and AVM characteristics, surgical results, clinical outcomes, complications, and long-term follow-up were reviewed.
Results
Between 2000 and 2013, 110 patients (57 male and 53 female) underwent obliteration of spinal AVFs and AVMs. The mean age at presentation was 42.3 years (range 18 months–81 years). There were 44 patients with AVFs and 66 with AVMs. The AVM group included 27 intramedullary, 21 conus medullaris, 12 metameric, and 6 extradural. The most common location was thoracic spine (61%), followed by cervical (22.7%), lumbar (14.5%), and sacral (1.8%). The most common presenting signs and symptoms included paresis/paralysis (75.5%), paresthesias (60%), pain (51.8%), bowel/bladder dysfunction (41.8%), and myelopathy (36.4%). Evidence of rupture was seen in 26.4% of patients. Perioperative embolization was performed in 42% of patients. Resection was performed in 95 patients (86.4%). Embolization alone was the only treatment in 14 patients (12.7%). One patient was treated with radiosurgery alone. Angiographically verified AVF and AVM obliteration was achieved in 92 patients (83.6%). At a mean follow-up duration of 30.5 months (range 1–205 months), 43 patients (97.7%) with AVFs and 57 (86.4%) with AVMs remained functionally independent (McCormick Scale scores ≤ 2). Perioperative complications were seen in 8 patients (7%). No deaths occurred. Temporary neurological deficits were observed in 27 patients (24.5%). These temporary deficits recovered 6–8 weeks after treatment. Recurrence was identified in 6 patients (13.6%) with AVFs and 10 (15.2%) with AVMs.
Conclusions
Spinal AVFs and AVMs are complex lesions that should be considered for surgical obliteration. Over the last several decades the authors have changed surgical strategies and management to achieve better clinical outcomes. Transient neurological deficit postoperatively is a risk associated with intervention; however, clinical outcomes appear to exceed the natural history based on patients’ ability to recover during the follow-up period. Due to the recurrence rate associated with these lesions, long-term follow-up is required.
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Gross BA, Du R. Spinal glomus (type II) arteriovenous malformations: a pooled analysis of hemorrhage risk and results of intervention. Neurosurgery 2013; 72:25-32; discussion 32. [PMID: 23096418 DOI: 10.1227/neu.0b013e318276b5d3] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The natural history and treatment results for spinal glomus (type II) arteriovenous malformations (AVMs) remain relatively obscure. OBJECTIVE To calculate spinal glomus (type II) AVM hemorrhages rates and amalgamate results of intervention. METHODS We performed a pooled analysis via the PubMed database through May 2012, including studies with at least 3 cases. Data on individual patients were extracted and analyzed using a Cox proportional hazards regression model to obtain hazard ratios for hemorrhage risk factors. RESULTS The annual hemorrhage rate before treatment was 4% (95% confidence interval [confidence interval]: 3%-6%), increasing to 10% (95% CI: 7%-16%) for AVMs with previous hemorrhage. The hazard ratio for hemorrhage after hemorrhagic presentation was 2.25 (95% CI: 0.71-7.07), increasing to 13.0 within the first 10 years (95% CI: 1.44-118). The overall rates of complete obliteration were 78% (95% CI: 72%-83%) for surgery and 33% (95% CI: 24%-43%) for endovascular treatment. Long-term clinical worsening occurred in 12% of patients after surgical treatment (95% CI: 8%-16%) and in 13% after endovascular treatment (95% CI: 7%-21%). No hemorrhages occurred after complete obliteration. After partial surgical treatment, the annual hemorrhage rate was 3% (95% CI: 1%-6%); no hemorrhages were reported over 196 patient-years after partial endovascular treatment. CONCLUSION Spinal glomus (type II) AVMs with previous hemorrhage, particularly within 10 years, demonstrated a greater risk of hemorrhage. Complete obliteration and even partial endovascular treatment significantly decreased their hemorrhage rate.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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