Risk factors of hematomyelia recurrence and clinical outcome in children with intradural spinal cord arteriovenous malformations

Spontaneous intramedullary hematoma following COVID-19 vaccination: A case report

A 67-year-old female was hospitalized due to right-sided hemiparesis and neck pain with rapid deterioration to a deep coma. She had received the Sinopharm vaccine 2 days earlier. MRI showed extensive cervicothoracic hematomyelia. She received intensive medical care for 2 months and was discharged. An 18-month follow-up showed significant neurological recovery.

Spinal cord arterio-venous shunts: From classification to therapeutic management

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.

Spinal vascular malformations: Angiographic evaluation and endovascular management

Spinal vascular malformations (SVM) are classified based on their location (intramedullary, perimedullary, radicular, extradural) and flow pattern (high-flow, low-flow, no arteriovenous shunt). High-flow SVMs are generally congenital lesions diagnosed in children and young patients without gender predominance. They present with hemodynamic disturbances, mass effect, or hemorrhages, but may also be discovered incidentally. Low-flow SVMs tend to be acquired lesions presenting in older men with progressive myelopathy caused by spinal venous hypertension. They are rarely associated with vascular syndromes but may accompany prothrombotic conditions. The sensitivity and specificity of conventional MRI are excellent for high-flow SVMs but poor for low-flow lesions, which are frequently diagnosed with extensive delays reducing the potential for favorable outcomes. The sensitivity of advanced MRI techniques remains unclear, notably for the detection of low-flow shunts without flow voids on conventional MRI. Catheter angiography remains the gold standard modality for the evaluation of the spinal vasculature and its disorders. SVMs can be treated by surgical or endovascular means. Initially plagued by high recurrence rates due to inadequate embolization material, endovascular techniques represent nowadays a valid alternative to surgery, thanks notably to the introduction of liquid embolic agents.

Introduction to Diagnostic and Therapeutic Spinal Angiography

This article describes the basic principles of diagnostic and therapeutic spinal angiography as practiced by the author, including catheterization and radioprotection techniques, the selection of endovascular devices and embolization agents, and procedural complications.

The role of spinal angiography in the evaluation and treatment of pediatric spinal vascular pathology: a case series and systematic review

OBJECT

While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With special implications regarding technique, radiation dose, and pathology, we sought to review our single-center experience with pediatric spinal vascular pathology and use a systematic review of the literature to further identify its role in pediatrics.

METHODS

A retrospective chart review was conducted under IRB approval for all patients age 0-18 years old who underwent spinal angiography at our institution between 2007 and 2018 for concern for spinal vascular pathology. A simultaneous systematic review was conducted via dedicated search terms in two distinct databases and reviewed to identify all studies referring to spinal angiography or angiograms in pediatric patients.

RESULTS

Six patients were included. Three patients (50%) had vascular malformations confirmed on diagnostic angiography and underwent subsequent endovascular treatment. Two patients (33.3%), one with hematomyelia and one with spinal cord infarction, had negative diagnostic angiograms. One patient (16.7%) had a spinal tumor and underwent angiography for further evaluation preoperatively. Spinal angiography was used to aid in diagnosis, preoperative planning, and treatment in these cases. It was demonstrated to be safe in this patient population, with no untoward events, minimal radiation dose, and possible therapeutic applications in select cases. The systematic review identified 11 studies regarding pediatric spinal angiography. These ranged from single case reports to case series of up to 38 patients and highlighted the role of spinal angiography in diagnosis, endovascular treatment, preoperative planning, and postoperative follow-up.

CONCLUSIONS

Spinal angiography may be used in a variety of scenarios to better understand the architecture of vascular spinal lesions and facilitate endovascular intervention. While its application in both adult and pediatric pathology is limited to select cases, spinal angiography remains a key diagnostic procedure when approaching vascular lesions or tumors of the spine, assessing for etiology of spinal cord infarcts, and in the evaluation of unexplained hemorrhage in the spinal canal.

Intradural spinal cord arteriovenous shunts in the pediatric population: natural history, endovascular management, and follow-up

BACKGROUND

Intradural spinal cord arteriovenous shunts represent a rare entity, particularly in the pediatric population, and clinical diagnosis can be challenging.

METHODS

We report the analysis of clinical, angioarchitectural, procedural, and follow-up data in a population of 36 children managed by our team between 2002 and 2017.

RESULTS

Hemorrhage occurred in 26 children (72%). Age at onset was 9.22 ± 3.65 years. Lesions were located at the thoracic level in 16 cases, at the cervical level in 15 cases, and the thoraco-lumbar region in 5 cases. A genetic or metameric syndrome was associated in 18 children (50%). Glue embolization provided complete occlusion in 5 children, subtotal in 7, and extensive in 14 without intraprocedural complications. We observed clinical normalization in 11 children, improvement in 11 cases, and stability in 3. Four children worsened during the follow-up, and one child died.

CONCLUSIONS

Endovascular staged glue embolization performed in experienced centers is safe in the treatment of pediatric intradural spinal cord arteriovenous shunts. Clinical and neuroradiological follow-up is mandatory, especially for pediatric patients.

Long term follow-up of endovascular management of spinal cord arteriovenous malformations with emphasis on particle embolization

Objective

To determine long term safety and efficacy of endovascular treatment of spinal cord arteriovenous malformations (AVMs), with calibrated particle embolization as a firstline approach.

Methods

We reviewed clinical and imaging data of consecutive patients who underwent endovascular treatment for both nidal and fistulous type spinal cord AVMs in our center, from 1990 to 2015. Outcome at the last follow-up was assessed by an independent observer.

Results

Embolization of spinal cord AVMs was performed in 61 patients, including 46 (75%) with particles (exclusively in 29 patients), 30 (49%) with cyanoacrylate, and 6 (10%) with combined surgical treatments. Particle embolizations were iterative in 33 patients (median number of sessions 5 (range 3–6)). Neurological deterioration after treatment occurred in 5 patients (cyanoacrylate=4, surgery=1, particles=0; P<0.001). At a median follow-up of 6 years (range 3–13 years), angiographic cure was obtained in 11/61 (18%) patients (nidal type=6/53 (11%), fistulous type=5/8 (63%)). In progressive forms, neurological improvement occurred in 16/28 (57%) patients, stabilized in 9/28 (31%), and worsened in 3/28 (12%). In hemorrhagic forms, the rebleeding rate was 4/14 patient years without standard treatment, 0/322 patient years in partial iterative treatment, and 0/15 patient years in angiographically cured lesions (P=0.001).

Conclusion

Our study suggests that particle embolization as a firstline therapy to treat spinal cord AVMs is safe and offers long term efficacy, especially for those with small, distal, and multiple shunts. Partial occlusion of the AVM may be sufficient to prevent rebleeding, without the potential risks of complete occlusion. Particle calibration and injection technique, ‘one by one’, are critical to safety. Cyanoacrylate embolization or surgery remains necessary if particle embolization fails to occlude large shunts.

Pial arteriovenous fistula of the spine in a child with hemiplegia

Pial arteriovenous fistula (AVF) is an extremely rare disease in children. When a child presents with sudden onset of hemiparesis and headache, it is very important to perform spinal magnetic resonance imaging (MRI) scanning for early diagnosis and treatment.