1
|
Guo Y, Yu J. Treatment of filum terminale pial arteriovenous fistulas in the sacral region: A case report and systematic review. Neuroradiol J 2023; 36:251-258. [PMID: 36086815 PMCID: PMC10268093 DOI: 10.1177/19714009221126017] [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] [Indexed: 11/16/2022] Open
Abstract
Spinal filum terminale pial arteriovenous fistulas (FT PAVFs) are uncommon. Most FT PAVFs are located in the lumbar region; far fewer are located in the sacral region. Due to the rarity of sacral FT PAVFs, the precise surgical dissection and removal of these lesions are challenging. Here, we report an FT PAVF in the sacral region. The patient was a 45-year-old male who suffered from progressive weakness and numbness of the bilateral lower limbs; his symptoms gradually worsened. Digital subtraction angiography (DSA) showed an AVF at the sacral canal at the S3-4 level. Microsurgical treatment with intraoperative DSA was performed, and the FT PAVF was resected. After the operation, the patient gradually recovered. Follow-up magnetic resonance imaging revealed a recession in the dilation of the spinal cord venous plexuses. A literature review was also performed, and a total of 14 FT PAVFs of the sacral region were identified. The patients identified in the literature review had an average age of 58.9 ± 12.9 years, and 92.9% of the patients were male. Spinal cord edema was present in 85.7% of the FT PAVF patients. Regarding treatment, 64.3% of the FT PAVF patients underwent microsurgical resection, 28.6% patients underwent endovascular treatment, and 7.1% patients underwent a hybrid operation; good outcomes were achieved with all three methods. Therefore, FT PAVF of the sacral region is a unique lesion whose angioarchitecture needs to be identified carefully; prompt treatment is necessary, and microsurgery can yield good outcomes.
Collapse
Affiliation(s)
- Yunbao Guo
- Department of Neurosurgery, the First Hospital of Jilin
University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, the First Hospital of Jilin
University, Changchun, China
| |
Collapse
|
2
|
Yamazaki H, Ozaki T, Kidani T, Fujimi Y, Nonaka M, Umegaki M, Yokota C, Fujinaka T. Coexisting filum terminale arteriovenous fistula and filum terminale lipoma treated with single-stage surgery: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22474. [PMID: 36647255 PMCID: PMC9844529 DOI: 10.3171/case22474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Both filum terminale arteriovenous fistulas (FTAVFs) and filum terminale lipomas (FTLs) are rare. Because of this rarity, there is a paucity of data regarding concomitant FTAVF and FTL, and the optimal treatment remains to be defined. The authors describe a patient with coexisting FTAVF and FTL treated with single-stage surgery. OBSERVATIONS A man in his 70s was referred to the authors' department because of a suspected spinal vascular malformation seen on magnetic resonance imaging that was performed to investigate lower limb weakness, intermittent claudication, and urinary incontinence. Previous imaging had shown a terminal lipoma with an internal flow void. Computed tomography angiography and digital subtraction angiography revealed an FTAVF, the feeder being a lateral sacral artery. The patient was treated surgically with curative intent. The FTL and tethered cord that had been identified by imaging were treated in the same procedure. Postoperative digital subtraction angiography showed absence of the abnormal vessels. The patient was discharged home on the 19th postoperative day. LESSONS When considering treatment, it is important to determine whether symptoms are attributable mainly to FTL, tethered cord, or FTAVF. One-stage treatment is useful because it eliminates both the FTAVF and the factors that led to its development.
Collapse
Affiliation(s)
- Hiroki Yamazaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Chuo-ku, Osaka, Japan,Department of Neurosurgery, Suita Municipal Hospital, Suita, Japan; and
| | - Tomohiko Ozaki
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Chuo-ku, Osaka, Japan
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Chuo-ku, Osaka, Japan
| | - Yosuke Fujimi
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Chuo-ku, Osaka, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Hirakata, Japan
| | - Masao Umegaki
- Department of Neurosurgery, Suita Municipal Hospital, Suita, Japan; and
| | - Chisato Yokota
- Department of Neurosurgery, Suita Municipal Hospital, Suita, Japan; and
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization, Osaka National Hospital, Chuo-ku, Osaka, Japan
| |
Collapse
|
3
|
A sacral filum terminale arteriovenous fistula fed by a left T9 artery of Adamkiewicz. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
4
|
Mull M, Dafotakis M, Schubert GA, Hans FJ, Jablawi F. Arteriovenous malformations of the filum terminale: clinical characteristics, angioarchitecture, and management of a rare spinal vascular pathology. Neurosurg Focus 2022; 53:E16. [DOI: 10.3171/2022.4.focus2289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The goal of this study was to describe clinical and neuroradiological features of arteriovenous malformations of the filum terminale (FT AVMs) and to present the authors’ diagnostic and therapeutic management in this rare disease.
METHODS
The presented cases were retrieved from a retrospectively collected database of all spinal vascular malformations treated between June 1992 and December 2021 at the Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital Aachen. Pretreatment and follow-up clinical and neuroradiological data were analyzed for this study.
RESULTS
Data in 15 patients with FT AVM with a mean age of 60 years were included, with an overall incidence of FT AVM of 19% among all spinal AVMs in our cohort. Twelve of 15 (80%) patients were men. Nonspecific but typical clinical and MR findings of thoracolumbar congestive myelopathy were found in all patients. Spinal MR angiography, performed in 10 patients, identified in all cases the arterialized FT vein as well as a lumbar/lumbosacral location of an AV shunt. Digital subtraction angiography (DSA) showed an arterial supply solely via the FT artery in 12/15 (80%) patients and via an additional feeder from the lumbosacral region in the other 3/15 (20%) patients. All patients were treated surgically. During 1-year follow-up, 2 patients presented with recurrent FT AVM due to further arterial supply from the lumbosacral region, and were treated surgically. Neurological status was improved in all patients within the 1-year follow-up, with marginal further changes during long-term follow-up.
CONCLUSIONS
Congestive myelopathy is the major pathological mechanism of symptoms in these patients, with no evidence for intradural bleeding. Missing the presence of possible multiple arterial supply of FT AVM during DSA may result in misdiagnosis and/or insufficient treatment. Due to the frequently prolonged course of FT artery, resection of the FT AVM may be a favorable treatment modality in comparison with endovascular treatment. Follow-up examinations are obligatory within the first 3 years after treatment, and further MR angiography and DSA examinations are indicated if congestive myelopathy persists.
Collapse
Affiliation(s)
- Michael Mull
- Department of Diagnostic and Interventional Neuroradiology,
| | | | | | | | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University, Giessen, Germany
| |
Collapse
|
5
|
Iampreechakul P, Liengudom A, Lertbutsayanukul P, Siriwimonmas S, Pongpech S. Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula: A Case Report. Asian J Neurosurg 2022; 17:88-94. [PMID: 35873833 PMCID: PMC9298594 DOI: 10.1055/s-0042-1748791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8–9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8–9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
Collapse
Affiliation(s)
| | - Anusak Liengudom
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | | | | | - Sirintara Pongpech
- Division of Interventional Neuroradiology, Department of Radiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand
| |
Collapse
|
6
|
Iampreechakul P, Liengudom A, Lertbutsayanukul P, Siriwimonmas S, Pongpech S. Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula. Asian J Neurosurg 2021; 16:638-644. [PMID: 34660387 PMCID: PMC8477807 DOI: 10.4103/ajns.ajns_185_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/04/2022] Open
Abstract
Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8–9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8–9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
Collapse
Affiliation(s)
| | - Anusak Liengudom
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | | | | | - Sirintara Pongpech
- Department of Radiology, Division of Interventional Neuroradiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand
| |
Collapse
|
7
|
Ryu B, Sato S, Niimi Y. Distortion and retraction injury at the hair-pin portion of the radiculomedullary artery during endovascular therapy for arteriovenous fistulas of the filum terminale. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
8
|
Farinha NC, Teixeira JC, Reis JH, Coiteiro D. Arteriovenous fistula of the filum terminale masqueraded as a failed back surgery syndrome - A case report and review of literature. Surg Neurol Int 2021; 12:53. [PMID: 33654556 PMCID: PMC7911147 DOI: 10.25259/sni_651_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/15/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The filum terminale arteriovenous fistulas (FTAVFs) are a very rare type of spinal vascular malformation. Clinically, these lesions could present with a progressive ascending myelopathy also called FoixAlajouanine syndrome. Due to the rarity of these vascular malformation, some can be misdiagnosed, submitted to unnecessary spinal surgery, and even masqueraded as a failed back surgery syndrome. Based on the present case and related literature, we review all the cases with similar history and describe factors that should raise awareness for diagnosis of this spinal vascular malformation. CASE DESCRIPTION We present a case of a patient with a FTAVF at the level of L5-S1 that presented with a FoixAlajouanine syndrome. He had been previously submitted to a lumbar decompressive laminectomy without sustained improvement. After the identification and surgical treatment of the vascular malformation, he had progressive neurological improvement. CONCLUSION FTAVF is a very rare spinal intradural spinal vascular malformation that can be masqueraded as a failed back surgery syndrome. In these cases, signs of ascending myelopathy should prompt awareness and vascular voids must be carefully evaluated in MRI.
Collapse
Affiliation(s)
- Nuno Cubas Farinha
- Department of Neurosurgery, Centro Hospitalar Universitário Lisboa Norte EPE, Avenida Professor Egas Moniz
| | - Joaquim Cruz Teixeira
- Department of Neurosurgery, CUF Infante Santo Hospital, Travessa do Castro, Lisbon, Portugal
| | - José Hipólito Reis
- Department of Neurosurgery, Centro Hospitalar Universitário Lisboa Norte EPE, Avenida Professor Egas Moniz
| | - Domingos Coiteiro
- Department of Neurosurgery, Centro Hospitalar Universitário Lisboa Norte EPE, Avenida Professor Egas Moniz
| |
Collapse
|
9
|
Ryu B, Sato S, Mochizuki T, Niimi Y. Spinal arteriovenous fistula located in the filum terminale externa: A case report and review of the literature. Interv Neuroradiol 2020; 27:451-455. [PMID: 33092430 DOI: 10.1177/1591019920968363] [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] [Indexed: 12/22/2022] Open
Abstract
A filum terminale arteriovenous fistula (FTAVF) is an extremely rare spinal arteriovenous fistula (AVF) and typically presents with myelopathy and conus medullaris syndrome caused by venous congestion in the spinal cord. Most reported FTAVFs are intradural pial AVFs with perimedullary drainage in the filum terminale interna. However, there are no reports of AVFs in the filum terminale externa (FTE). We describe a case involving a 68-year-old man with an AVF in the FTE who presented with progressive myelopathy and underwent successful endovascular treatment. We identified the specific shunt point by fusing postoperative computed tomography and magnetic resonance images. The features of the extradural sac AVF developed in the FTE may mimic those of a dural AVF with dural supply to the FTE covered by the dural component, unlike typical FTAVFs where the shunt develops at the pia mater. This case makes a significant contribution to the field by increasing the understanding of the clinical characteristics of an AVF that develops in the FTE and its angioarchitecture.
Collapse
Affiliation(s)
- Bikei Ryu
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan.,Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuki Mochizuki
- Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neuroendovascular Therapy, St. Luke's International Hospital, Tokyo, Japan
| |
Collapse
|
10
|
Namba K, Niimi Y, Ishiguro T, Higaki A, Toma N, Komiyama M. Cauda Equina and Filum Terminale Arteriovenous Fistulas: Anatomic and Radiographic Features. AJNR Am J Neuroradiol 2020; 41:2166-2170. [PMID: 33033040 DOI: 10.3174/ajnr.a6813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/01/2020] [Indexed: 11/07/2022]
Abstract
Intradural AVF below the conus medullaris may develop either on the filum terminale or the cauda equina (lumbosacral and coccygeal radicular nerves). Although not a few filum terminale AVFs are found in the literature, only 3 detailed cauda equina AVFs have been reported. Here, we analyze the angiographic and MR imaging findings of our cauda equina and filum terminale AVF cases, supplemented with literature research to characterize the radiologic features of the 2 entities. On angiography, filum terminale AVFs were invariably supplied by the extension of the anterior spinal artery accompanied by a closely paralleling filum terminale vein. Cauda equina AVFs were fed by either a radicular or a spinal artery or both arteries, often with a characteristic wavy radicular-perimedullary draining vein. On thin-section axial MR imaging, the filum terminale AVF draining vein joined the spinal cord at the conus medullaris apex, but that of the cauda equina AVF joined above the conus medullaris apex.
Collapse
Affiliation(s)
- K Namba
- From the Center for Endovascular Therapy (K.N., A.H.), Division of Neuroendovascular Surgery, Jichi Medical University, Tochigi, Japan
| | - Y Niimi
- Department of Neuroendovascular Therapy (Y.N.), St. Luke's International Hospital, Tokyo, Japan
| | - T Ishiguro
- Department of Neurointervention (T.I., M.K.), Osaka City General Hospital, Osaka, Japan
| | - A Higaki
- From the Center for Endovascular Therapy (K.N., A.H.), Division of Neuroendovascular Surgery, Jichi Medical University, Tochigi, Japan
| | - N Toma
- Department of Neurosurgery (N.T.), Mie University Graduate School of Medicine, Mie, Japan
| | - M Komiyama
- Department of Neurointervention (T.I., M.K.), Osaka City General Hospital, Osaka, Japan
| |
Collapse
|
11
|
Iampreechakul P, Tirakotai W, Wangtanaphat K, Lertbutsayanukul P, Siriwimonmas S. Filum Terminale Arteriovenous Fistula in Association with Degenerative Lumbosacral Spinal Canal Stenosis: Report of 3 Cases and Review of the Literature. World Neurosurg 2020; 138:231-241. [PMID: 32169619 DOI: 10.1016/j.wneu.2020.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Filum terminale arteriovenous fistulas (FTAVFs) are rare, and the pathogenesis of these fistulas remains unclear. They may be either congenital or acquired in origin. The authors report 3 cases of FTAVFs in association with severe spinal canal stenosis. The authors also review literature of FTAVFs associated with spinal canal stenosis. CASE DESCRIPTION All 3 cases harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction following long history of back pain, sciatica, and/or intermittent claudication. The fistulas were located around or at the level of spinal canal stenosis and supplied by the anterior spinal and/or lateral sacral arteries with cranial drainage from the dilated vein of the filum terminale to the perimedullary veins. The first and third cases were treated concomitantly by performing instrumented fusion with decompressive laminectomy along with occlusion of the fistula with good results. The second case was unsuccessfully treated by endovascular treatment through the lateral sacral artery and denied further surgical treatment. CONCLUSIONS Our 3 case reports may provide additional evidence supporting an acquired etiology of FTAVFs, probably secondary to the severe central canal stenosis. From our review, the level of the fistulas in most patients is correlated with the level of spinal canal stenosis. The authors preferred the concomitant surgical treatment by performing decompressive laminectomy and obliteration of the fistula in the same surgical session.
Collapse
Affiliation(s)
| | - Wuttipong Tirakotai
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | | | | | | |
Collapse
|
12
|
Lakhdar F, Benzagmout M, Chakour K, Chaoui MEF. Spinal Arteriovenous Fistulas of the Filum Terminale: Case Report and Literature Review. Asian J Neurosurg 2019; 14:1277-1282. [PMID: 31903378 PMCID: PMC6896622 DOI: 10.4103/ajns.ajns_100_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Spiinal arteriovenous fistulae (AVF) are an uncommon cause of myelopathy that require a high degree of suspicion to diagnose. Treatment strategies have not yet been established. Only a few cases of AVFs of the filum terminale (FT) have been reported. In this review, we describe clinical presentation, imaging, and treatment options for this rare type of spinal AV shunt. A 43-year-old male patient presented with progressive low back pain and paraparesis with gradually worsening bilateral foot paresthesias and sphincter dysfunction. He underwent magnetic resonance imaging, which revealed a hypersignal in the thoracolumbar cord and angiography diagnosed a microfistula of the FT. Surgery was preferred over endovascular treatment and we realized an L5 laminectomy to open the dura mater and found a hypertrophic FT. After identifying the fistula which was closely related to cauda equina, and dissecting the root from the fistula, a permanent clip was placed on the proximal part of the arterialized vein. Surgery was uneventful, and 6 months postoperatively, the patient has fully recovered. FT AVFs although rare should be considered as a differential diagnosis of progressive paraparesis, and successful surgery through clipping relies on the angioarchitecture of the shunt and the clinical manifestations of the patient.
Collapse
Affiliation(s)
- Fayçal Lakhdar
- Department of Neurosurgery, Hassan II Hospital, University Medical School of Fez, Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Mohammed Benzagmout
- Department of Neurosurgery, Hassan II Hospital, University Medical School of Fez, Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Khalid Chakour
- Department of Neurosurgery, Hassan II Hospital, University Medical School of Fez, Sidi Mohamed Ben Abdellah, Fez, Morocco
| | - Mohammed El Faiz Chaoui
- Department of Neurosurgery, Hassan II Hospital, University Medical School of Fez, Sidi Mohamed Ben Abdellah, Fez, Morocco
| |
Collapse
|
13
|
Arteriovenous Fistula of the Filum Terminale: A Case Report and Review of the Literature. World Neurosurg 2019; 130:42-49. [DOI: 10.1016/j.wneu.2019.06.136] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 11/19/2022]
|
14
|
Gao P, Li X, Li G. Retrograde Cannulation of the Draining Vein for Embolization of Filum Terminale Arteriovenous Fistula in the Lower Sacral Region. World Neurosurg 2019; 130:254-258. [PMID: 31299309 DOI: 10.1016/j.wneu.2019.06.236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/28/2019] [Accepted: 06/29/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Filum terminale arteriovenous fistulae (FTAVFs) are rare entities. For those with the fistulous point located in the lower sacral region (below S2), neither surgical nor endovascular strategies are the optimal treatment. CASE DESCRIPTION We describe 2 FTAVF cases with the fistulous point below S2: one had the anterior spinal artery (ASA) as a single feeder with a long distance to the fistula and the other developed an inaccessible feeder after the initial non-ASA feeder embolization. In a hybrid operating room, through an L4 laminectomy, we surgically exposed and cannulated the cephalad draining vein, other than the feeding arteries, to retrograde occlude the proximal draining vein along with the fistulous point and feeders using Onyx. All shunt points were obliterated with the help of intraoperative digital subtraction angiography. CONCLUSIONS Retrograde embolization of the draining vein to obliterate FTAVFs in the lower sacral region is feasible and complete. This technique may provide a new treatment option for FTAVFs.
Collapse
Affiliation(s)
- Peng Gao
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaoyu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
15
|
Lin HY, Lee YJ, Lin KC, Tsai CC. Clipping of spinal arteriovenous fistula of the filum terminale under intraoperative angiography guidance. FORMOSAN JOURNAL OF SURGERY 2019. [DOI: 10.4103/fjs.fjs_36_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
16
|
Takai K, Komori T, Taniguchi M. Angioarchitecture of Filum Terminale Arteriovenous Fistulas: Relationship with a Tethered Spinal Cord. World Neurosurg 2018; 122:e795-e804. [PMID: 30391599 DOI: 10.1016/j.wneu.2018.10.149] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Spinal arteriovenous fistulas at the filum terminale (filum AVFs) are rare. Treatment strategies have not yet been established, particularly for cases of filum AVF with lipoma. METHODS We report 7 cases of filum AVF with (n = 3) or without (n = 4) a tethered spinal cord by sacral terminal lipoma, with a focus on angiographic and operative findings. RESULTS All 7 patients (median age, 73 years; range, 40-84 years; men: n = 5) presented with slowly progressive paraparesis, lower extremity sensory disturbances, and bladder/bowel disturbances. Filum AVFs were fed by the filum artery, the distal segment of the anterior spinal artery supplied from the artery of Adamkiewicz. The arteriovenous shunt was located at the filum terminale and drained via the ascending filum vein. In 3 patients with filum AVFs without lipoma, the artery of Adamkiewicz originated from the thoracic segmental artery. In contrast, in 3 patients with filum AVFs with lipoma, the artery of Adamkiewicz originated from the lower lumber or sacral artery because of low-lying conus medullaris. In all patients, filum AVFs were completely obliterated by microsurgical resection of the filum terminale including the arteriovenous fistula. Recurrence was not reported in the follow-up period (median, 64 months), except for 1 patient who required additional surgery because of complex neurovascular structures. CONCLUSIONS Caution is needed when identifying the spinal level of occlusion of the fistula, particularly in cases of a tethered spinal cord by lipoma, because the feeding artery is associated with the artery of Adamkiewicz, which supplies the low-lying spinal cord in the sacral region.
Collapse
Affiliation(s)
- Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.
| | - Takashi Komori
- Department of Laboratory Medicine and Pathology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Makoto Taniguchi
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| |
Collapse
|
17
|
Hong T, Yu JX, Liu W, Bian LS, Yang F, Ma YJ, Ling F, Zhang HQ. Filum Terminale Arteriovenous Fistulas with Multiple Shunt Points: A Report of Two Exceptional Cases. World Neurosurg 2018; 118:235-239. [PMID: 30031960 DOI: 10.1016/j.wneu.2018.07.097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/10/2018] [Accepted: 07/11/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Filum terminale arteriovenous fistula (FTAVF) with multiple shunt points has not been reported in the literature. In previous studies, the angioarchitecture of FTAVFs was always featured with only one single shunt point, and such a uniformity had established the preconceived and conventional understanding of FTAVFs for clinicians. CASE DESCRIPTION The authors describe 2 exceptional cases of FTAVFs with multiple shunt points confirmed by open surgery, which means that the above understanding may lead to misdiagnosis and incomplete treatment in future. The surgery of both cases was performed in a hybrid operating room, and all of shunt points were obliterated with the help of intraoperative digital subtraction angiography. CONCLUSIONS The exceptional finding of these 2 cases is a renewal of the conventional understanding of FTAVFs, not only for the angioarchitecture of the lesions but also for the treatment strategy.
Collapse
Affiliation(s)
- Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Jia-Xing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Wei Liu
- Intensive Care Unit, People's Hospital of Yucheng City, Yucheng, Shandong, China
| | - Li-Song Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Yong-Jie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China
| | - Hong-Qi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; International Neuroscience Institute (China-INI), Beijing, China.
| |
Collapse
|
18
|
Giordan E, Bortolotti C, Lanzino G, Brinjikji W. Spinal Arteriovenous Vascular Malformations in Patients with Neural Tube Defects. AJNR Am J Neuroradiol 2017; 39:597-603. [PMID: 29284599 DOI: 10.3174/ajnr.a5498] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/30/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Neural tube defects, such as tethered cord, intradural lipoma, or myelomeningocele may coexist with spinal vascular malformations. The coexistence of these 2 rare entities is suggestive of a causal relationship between them, which may lead to further understanding of their pathogenesis. We present a series of 6 patients with epidural spinal arteriovenous fistulas associated with neural tube defects. MATERIALS AND METHODS We retrieved cases of spinal vascular malformations associated with neural tube defects seen at our institution. The clinical presentation, MR imaging/MRA and angiographic imaging, treatment outcomes, and long-term neurologic outcomes were analyzed. Descriptive statistical analyses are reported. RESULTS Six patients with epidural arteriovenous fistulas and neural tube defects were included in this study. The mean age at presentation was 42 years, and the most common presenting symptoms were lower extremity weakness followed by sensory disturbances and bladder/bowel dysfunction. In most cases (5/6), the fistulas were located at the sacral level. All cases were fed by the lateral sacral artery (6/6). Four patients had prior spine surgery, but the fistula was in the operative bed in 2 cases. All fistulas were extradural with secondary intradural venous drainage. Five patients underwent transarterial embolization with Onyx, and 1 patient had a treatment-related complication. CONCLUSIONS It is conceivable that there is a pathophysiologic link between neural tube defects and development of spinal vascular malformations. Delayed neurologic deterioration or high conus signal in a patient with a neural tube defect should suggest the possibility of such an association.
Collapse
Affiliation(s)
- E Giordan
- From the Departments of Neurologic Surgery (E.G., G.L.)
| | - C Bortolotti
- Department of Neurosurgery (C.B.), Istituto di Ricovero e Cura a Carattere Scientifico Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - G Lanzino
- From the Departments of Neurologic Surgery (E.G., G.L.) .,Radiology (G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - W Brinjikji
- Radiology (G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
19
|
Giordan E, Brinjikji W, Ciceri E, Lanzino G. Arteriovenous fistulae of the filum terminale. J Neurointerv Surg 2017; 10:191-197. [DOI: 10.1136/neurintsurg-2017-013309] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/09/2017] [Accepted: 08/24/2017] [Indexed: 01/12/2023]
Abstract
Filum terminale arteriovenous fistulae are a rare type of arteriovenous shunt generally characterized by a single direct communication between the artery of the filum terminale and a single draining vein. These intradural arteriovenous shunts are three times more common in men than women (mean age 55 years). Symptoms are related to venous congestion, vascular hypertension, and a putative chronic steal phenomenon which result in spinal cord ischemia and myelopathy. Interestingly, hemorrhage has never been reported as a mode of presentation. MRI demonstrates increased flow voids and T2 changes involving the conus and the lower spinal cord, and these findings are not dissimilar from those seen with the more common type 1 spinal dural arteriovenous fistulae. Thus conventional spinal angiography is necessary for a definitive diagnosis and to localize exactly the site of the fistula. Both surgical interruption of the fistula and endovascular embolization are safe and effective therapeutic modalities. However, because of the very small caliber of the feeding artery, endovascular therapy is often not feasible; and thus, surgery remains the method more commonly utilized for their treatment. Definitive treatment consists of obliteration of the direct arteriovenous shunt. In this review, we describe the anatomy, pathophysiology, clinical presentation, imaging, and treatment options of these less common intradural arteriovenous shunts.
Collapse
|
20
|
WITHDRAWN: A case of filum terminale arterial venous fistula needing a long arterial access for transarterial shunt obliteration. Interv Neuroradiol 2017; 23:NP2. [PMID: 28610470 PMCID: PMC6852424 DOI: 10.1177/1591019917695690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024] Open
|
21
|
Concomitant Lumbosacral Perimedullary Arteriovenous Fistula and Spinal Dural Arteriovenous Fistula. World Neurosurg 2017; 105:1041.e7-1041.e14. [PMID: 28684369 DOI: 10.1016/j.wneu.2017.06.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although multifocal spinal arteriovenous malformations (AVMs) have been reported before, the present case is the first case of 2 different types, including 1 perimedullary arteriovenous fistula and 2 spinal dural arteriovenous fistulas of lumbosacral AVMs, coexisting in 1 patient. We also report the use of hybrid techniques in treatment of concomitant lumbosacral spinal AVMs. CASE DESCRIPTION A 65-year-old man presented with a 4-year history of progressive sensory, motor, and sphincter dysfunction. Spinal magnetic resonance imaging and digital subtraction angiography showed 2 spinal dural arteriovenous fistulas (fed by the right L2 lumbar artery and the right lateral sacral artery, respectively) and 1 perimedullary arteriovenous fistula (fed by the filum terminale artery from the left L2 lumbar artery [i.e., filum terminale arteriovenous fistulas]. A hybrid technique was used to perform embolization of the right L2 spinal dural arteriovenous fistula and microsurgery of the L5 level filum terminale vein. The patient was asymptomatic 1 year later. CONCLUSIONS Multifocal spinal vascular malformations may coexist in 1 case, and standardized spinal digital subtraction angiography, including the bilateral internal iliac arteries and median sacral artery, should be performed to avoid a missed diagnosis. The concomitant phenomenon indicates that venous hypertension may be a risk factor for the development of arteriovenous fistulas. Hybrid techniques are effective in treatment of multifocal and complex spinal AVMs.
Collapse
|
22
|
A case of arteriovenous fistula of the cauda equina fed by the proximal radicular artery: anatomical features and treatment precautions. 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 2017; 27:281-286. [PMID: 28501955 DOI: 10.1007/s00586-017-5129-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/24/2017] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Arteriovenous fistula (AVF) of the cauda equina (CE) fed by the proximal radicular artery (PRA) is very rare, and the differentiation from that of the filum terminale (FT) is important to avoid treatment-related injury to the CE when endovascular treatment is selected. The authors describe a case of AVF of the CE fed by the PRA, demonstrate the anatomical features and discuss the treatment precautions. METHODS A 69-year-old man presented with a transient weakness of lower limbs. Spinal angiography and magnetic resonance (MR) imaging revealed AVF, of which the feeding artery arose from the anterior spinal artery (ASA), forming the fistula at L2 level to be drained into the longitudinal venous trunk. Under a tentative diagnosis of AVF of the FT, endovascular treatment was attempted but failed due to impossible catheterization into the ASA. Therefore, surgery was performed. RESULTS Intraoperative finding revealed that the feeding artery and draining vein were not on the FT but on the CE, resulting in the proper diagnosis of AVF of the CE. Surgical clips were applied to the draining vein closest to the fistula, and postoperatively the symptom improved gradually. Although we thoroughly reevaluated spinal angiography and MR images postoperatively, AVF of the CE fed by the PRA and that of the FT were not distinguishable. CONCLUSIONS The authors described a case of AVF of the CE fed by the PRA and demonstrated the difficulty of the differentiation from that of the FT. The utmost precautions are necessary when endovascular treatment is selected.
Collapse
|
23
|
Wajima D, Nakagawa I, Park HS, Haku T, Wada T, Kichikawa K, Nakase H. A case of filum terminale arterial venous fistula needed a long arterial access for trans-arterial shunt obliteration. Interv Neuroradiol 2017; 23:221-227. [PMID: 28133986 DOI: 10.1177/1591019916687716] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 78-year-old man was referred to our institution with a predominantly progressive numbness of both legs, and bladder dysfunction with urinary retention. He was diagnosed as the symptomatic arteriovenous fistula of the filum terminale (AVFFT). A trans-arterial embolization (TAE) of the arteriovenous shunt was planned for his symptomatic AVFFT. The long distance between the origin of the radiculo meningeal artery (Th8) and the site of the fistula (S1) resulted in the first TAE having a feeder occlusion. The length of accessible feeder in the first TAE was the longest (about 40 cm) as the past reports of the endovascular therapy. However, complete shunt occlusion was accomplished at a second session two weeks after the initial TAE because a more accessible feeder was developed by the initial feeder occlusion.
Collapse
Affiliation(s)
- Daisuke Wajima
- 1 Department of Neurosurgery, Nara Medical University, Japan
| | - Ichiro Nakagawa
- 1 Department of Neurosurgery, Nara Medical University, Japan
| | - Hun-Soo Park
- 1 Department of Neurosurgery, Nara Medical University, Japan
| | - Takahide Haku
- 1 Department of Neurosurgery, Nara Medical University, Japan
| | - Takeshi Wada
- 2 Department of Radiology, Nara Medical University, Japan
| | | | - Hiroyuki Nakase
- 1 Department of Neurosurgery, Nara Medical University, Japan
| |
Collapse
|
24
|
Hong T, Park JE, Ling F, terBrugge KG, Tymianski M, Zhang HQ, Krings T. Comparison of 3 Different Types of Spinal Arteriovenous Shunts below the Conus in Clinical Presentation, Radiologic Findings, and Outcomes. AJNR Am J Neuroradiol 2016; 38:403-409. [PMID: 27884878 DOI: 10.3174/ajnr.a5001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 09/06/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal arteriovenous shunts below the conus constitute 3 types of lesions, which have previously been mainly described in case reports, given their rarity, and are sometimes misdiagnosed. The purpose of this study was to describe the features of each type and compare these types as to epidemiologic features, clinical and radiologic presentations, treatment, and outcomes in a consecutive series of 48 cases. MATERIALS AND METHODS The prospectively collected data bases of 2 referral centers for spinal vascular lesions were retrospectively reviewed. Spinal arteriovenous shunts below the conus were defined as all dural and intradural shunts below the conus medullaris. Clinical features, radiologic findings, treatment results, and clinical outcomes were assessed. RESULTS There were filum terminale arteriovenous fistulas in 11 patients (22.9%), radicular arteriovenous shunts in 7 patients (14.6%), and spinal dural arteriovenous fistulas in 30 patients (62.5%). Radicular arteriovenous shunts presented at a younger age (P = .017) and with a higher incidence of back pain symptoms (P = .037). A tethered spinal cord was found in 54.5% of patients with filum terminale arteriovenous fistulas and 23.3% of patients with spinal dural arteriovenous fistulas. After treatment, the angiographic complete obliteration rate was 89.4% and spinal function was improved significantly (P < .001). CONCLUSIONS Three groups of spinal arteriovenous shunts below the conus can be differentiated according to clinical and radiologic features. Filum terminale arteriovenous fistulas are frequently associated with dysraphic malformations, which may suggest a particular embryologic origin.
Collapse
Affiliation(s)
- T Hong
- From the Department of Neurosurgery (T.H., F.L., H.Q.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - J E Park
- Department of Radiology and Research Institute of Radiology (J.E.P.), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - F Ling
- From the Department of Neurosurgery (T.H., F.L., H.Q.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | - M Tymianski
- Division of Neurosurgery (M.T.), Toronto Western Hospital, University of Toronto, Ontario, Canada
| | - H Q Zhang
- From the Department of Neurosurgery (T.H., F.L., H.Q.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - T Krings
- Department of Medical Imaging (K.G.T., T.K.)
| |
Collapse
|
25
|
Lumbar disc herniation exacerbating venous hypertension from a spinal perimedullary arteriovenous fistula of the filum terminale. J Neurol Sci 2016; 369:276-277. [PMID: 27653907 DOI: 10.1016/j.jns.2016.08.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 07/13/2016] [Accepted: 08/24/2016] [Indexed: 11/24/2022]
|