Glomus Cervical Arteriovenous Malformation Presenting with Intracranial Subarachnoid Hemorrhage: Clinical Case and Pial Resection Surgical Technique Description

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.

Spontaneous obliteration of a spinal perimedullary fistula

We herewith report a young patient who had an incidental spinal vascular malformation of the cervicomedullary junction discovered during a work-up for anosmia. Angiography demonstrated a perimedullary spinal arteriovenous fistula with supply from lateral spinal arteries arising from bilateral V3 level segmental arteries. It was decided to manage the patient conservatively with magnetic resonance imaging monitored biannually. On a recent follow-up magnetic resonance, nearly 10 years later, we noted a subtle change in caliber and imaging characteristics at the posterior margin of the cervical medullary junction. Repeat digital-subtraction angiography showed no evidence of early venous filling from the previously involved branches. Microcatheter exploration of the right lateral spinal artery confirmed spontaneous occlusion of the spinal perimedullary arteriovenous fistula, without any persistent shunting. Spontaneous resolution of a spinal vascular malformation is rare; this case demonstrates the dynamic nature of shunting vascular malformations and that spontaneous obliteration of arteriovenous shunts is possible.

Recurrence Rates Following Treatment of Spinal Vascular Malformations: A Systematic Review and Meta-Analysis

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.

Vascular Malformations of the Spinal Cord in Children

Vascular malformation of the spinal cord in children is a rare and complicated disease spectrum. We will start from the basic spinal cord vascular anatomy and the controversial classification of this kind of disease. Then, we will elaborate the clinical manifestations, diagnostic imaging and treatment of pediatric spinal vascular malformations based on the practical experience of our center and from literature.

Thoracic spinal arteriovenous malformation in a 16-year-old presenting with headache

Spinal arteriovenous malformations (sAVM) are abnormally developed spinal blood vessels with an increased risk of hemorrhage. Current literature regarding sAVMs is sparse and describes classic presentations in very young children or adults. We report a unique case of a sAVM in an adolescent patient. A 16-year-old female patient presented to the emergency department with a 3-day history of headaches. Initial CT showed no abnormalities. Worsening headaches led the patient to a neurology clinic and a fundoscopy revealed papilledema. The patient was transferred to a pediatric emergency department where repeat head CT showed a possible subarachnoid hemorrhage, and a cranial MRI/MRV showed what appeared to be a non-occlusive sinus venous thrombosis. CT angiography of the head and neck showed no evidence of thrombosis, but it did reveal possible upper thoracic vascular abnormalities. Thoracic MRI revealed an intradural sAVM at T3-T5. The sAVM was successfully resected with thoracic laminectomy with reconstructive laminoplasty. The patient experienced complications with development of right lower extremity motor and sensory deficits intra-op, but is showing continued improvement. This unique case encourages emergency medicine clinicians to expand the differential diagnoses for pediatric patients presenting with a headache and intracranial hypertension without a clear intracranial cause.

Intraoperative Identification of the Shunt Point of Spinal Arteriovenous Malformations by a Selective Arterial Injection of Saline to Subtract Signals of Indocyanine Green: Technical Note

BACKGROUND

It is crucial to identify a shunt point for spinal arteriovenous malformation (AVM) treatment. For this purpose, some intraoperative supports have been reported-intravenous injection of indocyanine green (ICG), selective arterial injection of ICG, and selective arterial injection of saline with a high frame rate digital camera. However, there are difficulties in accurately identifying the shunt point, especially if the lesion has multiple feeders. The aim of this technical note was to report a novel method, selective arterial injection of saline to subtract signals of ICG, to precisely identify perimedullary arteriovenous fistula shunt points having multiple feeding arteries.

METHODS

After exposing the lesion, a 4-F catheter was cannulated into the origins of the segmental artery. ICG was injected intravenously as a first step, and then heparinized saline solution was flushed from the catheter.

RESULTS

Compared with other methods, this method could identify the exact shunt point and was effective for certain shunt point obliterations.

CONCLUSIONS

Despite having similar invasiveness, selective arterial injection of saline to subtract signals of ICG is superior to previously described techniques, such as selective arterial injection of ICG. Therefore, it will be useful in spinal arteriovenous malformation surgical treatment.

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.

Massive subarachnoid hemorrhage during type iv spinal arteriovenous malformation embolization. An endovascular procedure complication

Spinal arteriovenous malformations are rare diseases with a low prevalence and a complex diagnosis that usually requires the several neuroscience disciplines collaboration. Multidisciplinary approach requires fluid communication, favorable work environment and a correct social relationship, thus avoiding the conflict of interest appearance. We reported a 31 years old female referred to our department with progressive asymmetric spastic paraparesia for 10 months of evolution and occasional bladder dysfunction. With the diagnosis of a type IV arteriovenous malformation, a scheduled embolization was performed resulting in a massive subarachnoid hemorrhage due to the ASA laceration requiring an emergency bifrontal craniectomy. We discuss the neurosurgeońs role in complications during endovascular spinal vascular pathology treatment.

Ayub Khan Ommaya (1930-2008): Legacy and Contributions to Neurosurgery

Ayub Khan Ommaya (1930-2008) was a pioneering neurosurgeon of Pakistani origin who is widely known for inventing the Ommaya reservoir, a ventricular catheter with a mushroom-shaped dome for administration of intraventricular therapies. As a Rhodes Scholar at Oxford, Ommaya developed an early interest in studying traumatic brain injury. Over the course of his career, Ommaya employed subhuman primate models to better understand mechanisms underlying human cerebral concussion. His work on traumatic brain injury led to the creation of the National Center for Injury Prevention and Control, a center for injury prevention research at the Center for Disease Control. This historical paper visits Ommaya's life story and recounts his key contributions to neurosurgery.

Pediatric Dilemma: Endovascular versus Surgical Intervention for Spinal Vascular Malformations

OBJECTIVE

Spinal arteriovenous malformations (AVM) manifest in the pediatric population very differently from the ones in adulthood. Despite that fact, the treatment strategy is quite the same, which provokes a question - whether some of the therapies have an advantage and if so, in which age group.

METHODS

For this reason, the authors searched the world literature between 1989 and 2018 for spinal AVM in children and further categorized the studies into two age groups: < 12 and ≥12.

RESULTS

The total number of included studies in this meta-analysis is 35. Seventeen of them are on the subject of AVM and 15 on the subject of arteriovenous fistula. Three studies encompass both types of lesions.

CONCLUSION

After processing the data, we observed that there is no relationship between age group and the utilized management, except for the endovascular AVF in children less than 12 years of age. Because of this, it should be strongly considered in further management planning.

Spinal extradural arteriovenous fistula with intradural drainage: three surgical cases with long-term follow-up

Spinal extradural arteriovenous fistulas (SEDAVF) with intradural drainage are uncommon vascular lesions that cause venous congestive myelopathy. We present three SEDAVF with intradural drainage treated with surgical disconnection of the intradural drainage via a single level laminectomy, followed by transarterial embolization (TAE) with Onyx if spontaneous thrombosis of the extradural fistula did not occur spontaneously. All patients improved their neurological condition and no congestive myelopathy recurrence was noted after mean follow-up of 84 months. We believe that SEDAVF with intradural drainage constitute a specific entity that should be included in the classifications of spinal arteriovenous malformations.

Arterial Hypertension Is Associated with Symptomatic Spinal Dural Arteriovenous Fistulas

OBJECTIVE

To determine possible systemic factors that may induce or be associated with the pathogenesis and pathologic course of spinal dural arteriovenous fistulas (SDAVFs), the most common type of arteriovenous disorder of the spinal cord and its meninges.

METHODS

We assessed the role of possible systemic (vascular) risk factors (arterial hypertension, diabetes mellitus, fat metabolism disorders, and nicotine dependence) by comparing the prevalence of these risk factors in an SDAVF cohort of 59 patients with the prevalence in the general population.

RESULTS

Age-corrected prevalence of arterial hypertension in the SDAVF cohort was significantly higher than in the general population (P < 0.001). Prevalence of diabetes mellitus (P = 0.150.), nicotine dependence (P = 0.561), adiposity (P = 0.217), and fat metabolism disorders (P = 0.125) did not differ from prevalence of comparable cohorts in the general population.

CONCLUSIONS

Our results and data from the literature suggest that arterial hypertension may play an important role in the development of SDAVF-related symptoms or the development of SDAVFs in the presence of other predisposing factors.