Combined spinal intramedullary arteriovenous malformation and lipomyelomeningocele

Congenital Spinal Lipomatous Malformations. Part 1. Spinal Lipomas, Lipomyeloceles, and Lipomyelomeningoceles

Background: Lumbosacral spinal lipomas and lipomyeloceles are usually identified in early childhood. Terminology, histopathology, and diagnosis for these malformations can be confusing. Materials and Methods: This is a PubMed review with comparison of embryology, gross, and histopathology, and reporting requisites for these and related closed spinal malformations. Results: The spinal lipoma group (congenital spinal lipomatous malformations) includes subcutaneous, transdural, intradural, and noncontiguous malformations stretching through the entire lower spinal region. This lipomyelocele trajectory overlaps the embryonic tail's caudal eminence. Histopathologically, the lipomyelocele spectrum is a heterogeneous, stereotypical set of findings encountered from dermis to spinal cord. Diagnosis requires detailed correlation of images, intraoperative inspection, and histopathology. Conclusions: Appropriate terminology and clinicopathologic correlation to arrive at a diagnosis is a critical activity shared by pathologist and clinician. Prognostic and management differences depend on specific diagnoses. Familial and genetic influences play little if any role in patient management in closed spinal malformations.

Angioarchitecture of Filum Terminale Arteriovenous Fistulas: Relationship with a Tethered Spinal Cord

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.

Coincidence of Tethered Cord, Filum Terminale Lipoma, and Sacral Dural Arteriovenous Fistula: Report of Two Cases and a Literature Review

Spinal dural arteriovenous fistula (SDAVF) is the most common vascular malformation of the spine in adults. However, the coincidence of tethered cord syndrome, lipoma, and SDAVF on the sacral level is exceptionally rare. We describe two patients, probably the fifth and sixth ever reported. The first was a 33 year-old female who underwent surgical cord de-tethering. Surprisingly, a sacral SDAVF was discovered intraoperatively, despite negative digital subtraction angiography (DSA). The second patient was a 30 year-old male with similar pathologies. After three failed embolizations, the fistula was surgically disconnected. Both patients recovered well. A review of patients with sacral SDAVF coexisting with spinal dysraphism, with an emphasis on the basis of symptoms was done. As a rule, in these coincident disorders, the SDAVF was the direct cause of increasing symptoms. Previous reports and our findings reveal that surgery might be superior to endovascular embolization for treating sacral SDAVFs with coexisting entities, because surgery offers a one-step treatment.

Spinal Arteriovenous Vascular Malformations in Patients with Neural Tube Defects

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.

Spinal arteriovenous fistula coexisting within a spinal lipoma: report of two cases

INTRODUCTION

Spinal lipoma and spinal arteriovenous fistula (sAVF) are different pathologies and their co-existence is extremely rare. Here we reported two cases of adult-onset sAVF occurring within a spinal lipoma and with review the literature in an attempt to identify the mechanisim of and optimal treatment of this condition.

CASE PRESENTATION

Case 1 was a 51-year-old man who was treated by embolization of the feeding artery and ligation of the draining vein. Case 2 was a 53-year-old man who was treated by embolization and resection of the tumor containing the shunt zone. In both cases, symptoms improved after surgery. However, in Case 1, angiography at 1 month after the surgery revealed recurrence of the arteriovenous shunt.

DISCUSSION

A literature search revealed only nine other similar case reports. All cases, including ours occurred in adults. In almost all cases, the shunt was located within the spinal lipoma. Pathologic examination revealed venous hypertension, but no evidence of congenital vascular malformation. Given that lipomas release angiogenic factors, the presence of a spinal lipoma may indicate its involvement in the development of acquired sAVF. Our two cases might represent a new subtype of sAVF. Based on our experiences, we recommend resection of the tumor containing the shunt for the management of sAVF.

Extraspinal type I dural arteriovenous fistula with a lumbosacral lipomyelomeningocele: a case report and review of the literature

Seven cases of adult spinal vascular malformations presenting in conjunction with spinal dysraphism have been reported in the literature. Two of these involved male patients with a combined dural arteriovenous fistula (DAVF) and lipomyelomeningocele. The authors present the third case of a patient with an extraspinal DAVF and associated lipomyelomeningocele in a lumbosacral location. A 58-year-old woman with rapid decline in bilateral motor function 10 years after a prior L4-5 laminectomy and cord detethering for diagnosed tethered cord underwent magnetic resonance imaging showing evidence of persistent cord tethering and a lipomyelomeningocele. Diagnostic spinal angiogram showed a DAVF with arterial feeders from bilateral sacral and the right internal iliac arteries. The patient underwent Onyx embolization of both feeding right and left lateral sacral arteries. At 6-month follow-up, MRI revealed decreased flow voids and new collateralized supply to the DAVF. The patient underwent successful lipomyelomeningocele exploration, resection, AV fistula ligation, and cord detethering. This report discusses management of this patient as well as the importance of endovascular embolization followed by microsurgery for the treatment of cases with combined vascular and dysraphic anomalies.

Perimedullary arteriovenous fistulas in children: report on six cases

BACKGROUND

Perimedullary arteriovenous fistulas (PMAVFs) are rare spinal lesions and even more uncommon in children.

OBJECTIVE

The aim of this study was to document rare occurrences of this type of arteriovenous malformation in six children treated at our institution.

METHODS

The clinical data, radiological findings, and treatment in six cases of PMAVFs were reviewed. Six patients with PMAVFs were managed at our institution over a 5-year period. The patients (four girls and two boys), ranging in age from 6 to 15 years, presented with initially fluctuating, and eventually permanent and progressive, sudden-onset paraparesis, sensory disturbances, and sphincter dysfunction. The duration of symptoms before diagnosis ranged from 1 week to 13 years.

RESULTS

All the patients underwent magnetic resonance imaging and spinal selective angiography, which demonstrated the characteristic imaging of an arteriovenous fistula. Embolization of the arteriovenous fistula was initially attempted in three patients with successful occlusion of the fistula in two. For the remaining cases, open surgery was performed, with complete occlusion of the fistula. There was no morbidity, regardless of the treatment performed. All the patients experienced neurological improvement after treatment.

CONCLUSIONS

No specific clinical or radiological characteristic of PMAVFs in the pediatric population was observed when our series was compared with a general series. Early diagnosis and timing of the therapeutic intervention seemed to avoid the development of irreversible ischemic myeloradiculopathy and prevented hemorrhage. Treatment for PMAVFs is difficult to standardize because these are extremely rare lesions with different angioarchitecture configurations.

Current approaches to the treatment of paraneoplastic encephalitis

Paraneoplastic neurological syndromes (PNSs) cover a wide range of diseases and involve both the central nervous system (CNS) and peripheral nervous system. Paraneoplastic encephalitis comprises several diseases such as paraneoplastic cerebellar degeneration (PCD), limbic encephalitis (LE), paraneoplastic encephalomyelitis (PEM), brainstem encephalitis, opsomyoclonus syndrome, in addition to other even less frequently occurring entities. LE was the first historically identified CNS PNS, and similarities between other temporal lobe diseases such as herpes encephalitis have been elucidated. In the past few decades several autoantibodies have been described in association with LE. These encompass the classical 'onconeuronal' antibodies (abs) such as Hu, Yo, Ri and others, and now additionally abs towards either ion channels or surface antigens. The clinical core findings in LE are various mental changes such as amnesia or confusion, often associated with seizures. Careful characterization of psychiatric manifestations and/or associated neurological signs can help to characterize the syndrome and type of ab. The treatment options in LE depend on the aetiology. In LE caused by onconeuronal abs, the treatment options are poor. In two types of abs associated with LE, abs against ion channels and surface antigens (e.g. NMDA), immunomodulatory treatments seem effective, making these types of LE treatable conditions. However, LE can also occur without being associated with cancer, in which case only immunomodulation is required. Despite effective treatments, some patients' residual deficits remain, and recurrences have also been described.

Complex spinal-paraspinal fast-flow lesions in CLOVES syndrome: analysis of clinical and imaging findings in 6 patients

CLOVES syndrome is a complex disorder of congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal/scoliosis/spinal anomalies. We report the occurrence of spinal-paraspinal fast-flow lesions within or adjacent to the truncal overgrowth or a cutaneous birthmark in 6 patients with CLOVES syndrome.

[Imaging of spinal tumors]

Spinal tumors are often categorized into extradural, intradural extramedullary, or intramedullary. Although this classification represents somewhat of an overgeneralization as a lesion may reside in two compartments, it still helps to characterize spinal tumors. In the intradural, extramedullary space, primary tumors, such as neurofibroma and meningioma, are relatively common. Secondary tumors or leptomeningeal enhancement also occur. In the intramedullary space, primary tumors are far more common than secondary tumors or metastases.