Spinal vascular malformations: treatment strategies and outcome

Microsurgery Versus Embolization for Spinal Cord Arteriovenous Malformations: A Proposed Grading System

BACKGROUND AND OBJECTIVES

Comparing microsurgery and embolization for spinal cord arteriovenous malformations (SCAVMs) is challenging because of the disease's rarity and the highly heterogeneous angioarchitecture. The aim of this study was to compare outcomes between microsurgery and embolization using a grading system for SCAVMs that effectively stratifies angioarchitectural complexities.

METHODS

A total of 714 patients were included, with 308 undergoing microsurgery. The grading system was developed based on independent risk factors of incomplete resection, including anterior sulcal artery supply, metameric manifestations, the maximum diameter of lesion, and lesion depth. Each parameter was assigned one point, stratifying angioarchitectural complexities of SCAVMs into five grades.

RESULTS

Microsurgery carried significantly higher treatment risks than embolization across all grades. For patients scoring 0 to 2 points, microsurgery achieved significantly higher complete obliteration rates than embolization. For patients scoring 3 or 4 points, the complete obliteration rates between the two methods were similar. Long-term clinical deterioration after microsurgery was significantly more frequent after embolization for patients scoring 1; for patients scoring 0, the higher long-term deterioration rate after embolization was also observed, but not statistically significant; for patients scoring 2 to 4 points, risks of long-term clinical deterioration between the two methods were comparable. At the last follow-up, the rate of poor prognosis was similar between the two methods for patients scoring 0 points. For the remaining groups, microsurgery showed a worse prognosis.

CONCLUSION

Embolization should be the primary treatment option for patients with SCAVMs; however, microsurgery should be considered as an alternative for patients scoring 0 or 1 point if endovascular treatment fails to achieve complete obliteration.

Ruptured arteriovenous malformation of Conus medullaris in infancy: A case report of an extremely rare emergency

BACKGROUND

Ruptured arteriovenous malformation (AVM) of conus medullaris in the pediatric population is extremely rare. This pathology can lead to severe permanent sequela if it is not treated properly. However, controversy over management protocols persists especially in pediatric patients.

CASE PRESENTATION

We report a 5-month-old infant admitted for an AVM of conus medullaris with a hemorrhagic complication. The child presented with sudden lower limb weakness. Magnetic Resonance Imaging (MRI) demonstrated the etiology as a bleeding AVM of the conus medullaris causing massive spinal cord compression and surrounding edema. Because of the very young age and the emergency presentation, digital subtraction angiography was not feasible. Emergency surgery was indicated aiming at evacuating the hematoma and decompressing the spinal cord. Intraoperatively, after bilateral laminectomy, the spinal cord showed massive edema, the hematoma was removed and duroplasty was performed with autologous fascia. Two weeks postoperatively, the patient limb motor function on both sides showed gradual improvement.

DISCUSSION

Thorough clinical examination and MRI investigation played an important role in early and accurate diagnosis of this pathology. Decision on emergency management strategy needs to be carefully made involving neurosurgeons, neurologists, and radiologists. Definitive management might not be achieved by a single surgical procedure and requires a combination of different treatment modalities.

CONCLUSIONS

Ruptured arteriovenous malformation of conus medullaris at a very young age is a clinical formidable challenge. This type of neurological emergency requires prompt diagnosis and treatment to limit the irreversible injury and enhance functional recovery. Multidisciplinary collaboration is crucial to achieving these goals.

Dual-Source Computed Tomography Angiography versus Time-Resolved Contrast-Enhanced Magnetic Resonance Angiography for Diagnosis of Spinal Vascular Malformations: A Retrospective Study

OBJECTIVE

To investigate the performance of time-resolved angiography with stochastic trajectories (TWIST-MRA) and dual-source CT angiography (CTA), applied independently and in combination, for preoperative assessment of spinal vascular malformation (SVM).

METHODS

This retrospective study included 77 patients with suspected SVM who underwent TWIST-MRA, CTA, and digital subtraction angiography between September 2019 and December 2022. Precision recall curve analysis was used to assess diagnostic performance. The feeding artery and fistula location were evaluated using radiologist confidence level by CTA and TWIST-MRA.

RESULTS

Among the 77 patients, 71 had digital subtraction angiography-confirmed SVM (cervical, n = 7; thoracolumbar, n = 60; deep lumbosacral, n = 4) and 6 did not have SVM. Both TWIST-MRA and CTA showed excellent accuracy (96.1% vs. 94.8%) and sensitivity (98.6% vs. 97.2%) for diagnosis of SVM subtypes. TWIST-MRA performed slightly better than CTA in identifying the feeding artery and fistula (area under the curve-precision recall, 0.958 vs. 0.944); however, sensitivity was not statistically different (P = 0.512). Among SVM patients, the radiologist confidence levels in identifying feeding artery and fistula of SVMs were significantly higher with CTA+TWIST-MRA than with TWIST-MRA alone (P = 0.007). The radiologist confidence levels were significantly higher with CTA alone and CTA+TWIST-MRA compared to TWIST-MRA alone for fistula identification of cervical and deep lumbosacral SVMs (P < 0.001).

CONCLUSIONS

Both TWIST-MRA and CTA are reliable for diagnosing SVM and localizing the feeding artery and fistula. While TWIST-MRA remains the primary technique, the addition of CTA can improve diagnostic confidence. CTA may be considered as an alternative to TWIST-MRA for SVMs in the cervical and lumbosacral regions.

Foix-Alajouanine syndrome: a comprehensive overview of rare but relevant diagnosis

Introduction

Foix-Alajouanine syndrome (FAS) is an uncommon neurological disorder marked by the gradual development of spinal cord congestion. First documented by Foix and Alajouanine in 1926. Although it is infrequent, delayed or misdiagnosis is nonetheless prevalent, resulting in inadequate therapy and unfavorable results.

Methods

Using the PubMed database, MEDLINE, and EMBASE, we collected data on FAS patients and conducted a pooled analysis. The term 'FAS' was used to search for related articles. Our search was restricted to previous clinical case reports or series that were published in English. Non-English articles were excluded. We included the articles in the period from 1974 to 2024. Articles were eligible if the radiographic and clinical findings were indicative of FAS. A thorough research analysis was performed, examining case reports that specifically addressed this issue. This study examines the clinical symptoms, difficulties in diagnosis, methods of treatment, and outcomes related to FAS.

Results

FAS predominantly impacts the elderly population. A total of 26 patients were diagnosed with FAS. The median age of affected individuals was 53 (SD ±15.96). The ratio of males to females is roughly 5:1. The clinical manifestations encompass gradual muscle weakness and sensory impairments. The diagnosis is dependent on radiological evaluations, specifically MRI and digital subtraction angiography. Possible treatments include endovascular therapy, surgical closure of arteriovenous fistula, or a combination of the two. Significant improvements in neurological impairments can be achieved by early intervention.

Conclusion

The diagnosis of FAS continues to be difficult due to its infrequency and varied clinical manifestations. Prompt and precise diagnosis is essential for proper intervention, typically utilizing endovascular or surgical methods. Additional research is required to determine prognostic markers and enhance long-term care techniques for this rare neurological condition.

Rare clinical presentation of a ruptured spinal bulbomedullary arteriovenous malformation: a case report

Introduction and importance

Spinal arteriovenous malformations (AVMs) are a rare condition that has a high risk of bleeding and complications. The authors present the case of a spinal arteriovenous malformation in an unusual location and presentation.

Case presentation

A 67-year-old man with subarachnoid hemorrhage due to a ruptured spinal arteriovenous malformation type IVa, with associated bulbomedullary aneurysm, which was managed conservatively due to the high risk of complications and mortality.

Clinical discussion

Spinal AVMs have had different management and treatments over the years, so conservative management remains an option when arterial cannulation is complex and surgery carries a high risk of complications.

Conclusion

Due to the high risk of complications of surgery in this location, conservative treatment is an option for the management of such cases with good outcomes.

Hybrid open-endovascular onyx embolization of spinal type IVb perimedullary spinal arteriovenous fistula through direct posterior spinal vein access: A case report

Background

Spinal arteriovenous fistulas (SAVFs) are direct communication between arteries and veins without intervening abnormal vessel nidus, which often results in venous congestion and spinal cord dysfunction. Ventrally located SAVF can be challenging to treat through traditional open or endovascular approaches.

Case Description

We describe a hybrid (open/endovascular) procedure in a 72-year-old male with a Takai Type IVb SAVF presenting with paraparesis and sphincter dysfunction. Imaging revealed a conus medullaris SAVF in which the main fistulous connection was located ventrally. The conventional endovascular approach was deemed risky, and open surgery failed in the first attempt. The SAVF was resolved using a hybrid approach: under direct visualization, an engorged dorsal vein was punctured with an Angiocath, and a fluoroscopy-guided microcatheter was advanced through it to reach and embolize the ventral perimedullary fistulous connection. After surgery, his progressive neurological decline stabilized, radiographic spinal cord edema improved, and follow-up angiography confirmed obliteration of the fistula. Neurological function remained at the preoperative baseline.

Conclusion

This approach may be a treatment for selected cases of type IVb SAVF. Easily accessible feeding vessels are coagulated and cut; the inaccessible ones can be embolized endovascularly during the same procedure.

Endovascular embolization combined with anterior cervical corpectomy for treatment of cervical spinal dural arteriovenous fistula

Background

The two main treatments for spinal dural arteriovenous fistula (SDAVF) include microsurgical occlusion or endovascular embolization (i.e., the latter alone has high recurrence rates). Here, we combined both strategies to treat/obliterate a cervical SDAVF more effectively.

Case Description

A 34-year-old male presented with a marked decline in mental status attributed to an infratentorial subarachnoid hemorrhage. The left vertebral angiogram revealed a ruptured, low cervical SDAVF. He underwent successful occlusion of the spinal fistula utilizing super selective catheterization and endovascular embolization (i.e., utilizing Onyx-18 for the obliteration of target arteries). Due to significant SDAVF accompanying vessel recruitment/complex angioarchitecture, we additionally performed a C5 anterior corpectomy/fusion to afford direct access and complete surgical SDAVF occlusion. Three and 6 months later, repeated angiograms confirmed no recurrent or residual SDAVF.

Conclusion

We successfully treated a low cervical SDAVF using a combination of endovascular embolization and direct surgical occlusion through an anterior C5 corpectomy with a fusion approach.

A Rare Case of Cervical Spinal Arteriovenous Malformation: A Case Report

Arteriovenous malformation (AVM) is an abnormal connection of vasculature resulting in capillary bed bypassing and leading to neurological deterioration and high risk of bleeding. Intramedullary AVMs in the cervical spinal cord are rare and require precise diagnostics and treatment. We present a clinical case of recurrent AVMs in a 28-year-old Caucasian female with sudden and severe neck pain and variable neurological symptoms along with current diagnostic and treatment modalities. Conservative treatment was partially effective. MRI and DSA confirmed AVMs at C4 level with subsequent several endovascular treatment sessions at the age of 15 and 24 with mild neurological improvement. Afterwards the patient underwent rehabilitation with minor neurological improvement. This case highlights the clinical progression and treatment of AVMs along with showcasing current pathophysiology, classification, and imaging.

A Case Report of Spinal Arteriovenous Fistula: Vague Presentation and Successful Outcome

Spinal arteriovenous fistula (spinal AVF) malformation is one of the rare spinal vascular diseases. Its presentation could be misleading as the patient presents with spinal cord dysfunction, including motor power loss.  Early detection is essential and requires a high suspicion by the providing physician so the patient can be rightfully directed to the proper team with vascular intervention resources. Efficient management leads to promising outcomes with patient recovery. We are presenting a case with progressing motor and sensory neurological deficits that had a vague clinical course. After a prompt diagnosis of spinal AVF, the patient was referred to the neuro-vascular specialist, who performed an embolization of the spinal AVF. The patient had an excellent outcome and was discharged to a rehabilitation facility.

Knowledge, attitudes and practices regarding spinal vascular malformations among doctors in China: a cross-sectional study

OBJECTIVE

Knowledge, attitude and practice (KAP) models are essential tools for assessing healthcare professionals' understanding, beliefs and behaviours towards specific health issues. This study aimed to explore the KAP of Chinese doctors in diagnosing and treating spinal vascular malformations (SVM).

DESIGN

A web-based cross-sectional survey.

SETTING

This study was conducted between October and December 2022 through a self-administered questionnaire.

PARTICIPANTS

Participants include full-time doctors who voluntarily participate. Doctors in advanced training, regular training or internships were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

The KAP scores of Chinese doctors in diagnosing and treating SVM measured by the questionnaire.

RESULTS

A total of 517 doctors participated in the study, mostly in Shaanxi, China, working in SVM-relevant departments (n=396) or other departments (n=121). The doctors achieved an average knowledge score of 9.66±1.95 (range: 0-12), attitude score of 22.16±1.71 (range: 6-30) and practice scores of 46.13±5.35 for those in SVM-relevant departments (neurosurgery, orthopaedics and neurology) and 8.50±1.25 for those in other departments, respectively, revealing doctors have adequate knowledge, positive attitude and good practice, and those in SVM-relevant departments showing more adeptness compared with those in other departments. Moreover, multivariate logistic regression analysis showed that knowledge about SVM (OR=1.72, 95% CI 1.11 to 2.65, p=0.015), holding a master's degree (OR=1.85, 95% CI 1.14 to 3.00, p=0.013) and working in orthopaedics (OR=0.34, 95% CI 0.13 to 0.88, p=0.026) were independently associated with good attitude.

CONCLUSION

Chinese doctors showed adequate knowledge, moderate attitudes and good practice regarding SVM. A continuing education programme may improve clinical practitioners' ability to manage SVM.

An Unusual Cause of Neck Pain and Headache in Pregnancy

A previously healthy 21-year-old Caucasian female G1P0 at 32 weeks gestation presented to the ED for an episode of syncope. She also complained of headaches, neck pain, and blurry vision. Physical examination revealed a healthy pregnant female. Neurological examination demonstrated Grade III papilledema but was otherwise unremarkable. CT brain revealed hydrocephalus and intraventricular hemorrhage of unclear etiology MRI of the head was negative for a mass lesion. MRA/MRV of the head was negative, ruling out cavernous sinus thrombosis. Lumbar puncture was bloody but negative for infection. Infectious workup, including HSV, toxoplasmosis, and neurocysticercosis, was negative. An intraventricular drain was placed for hydrocephalus. While in the hospital, she developed sudden left-sided weakness, prompting an emergency C-section. Further workup with CT angio of the brain and neck revealed an arteriovenous malformation (AVM) involving the anterior spinal artery and adjacent venous plexus. Digital subtraction angiography showed a C2-3 pial AVM with a partially thrombosed nidal aneurysm. She was transferred to an outside hospital for embolization. Embolization obliterated the aneurysm, but residual flow remained in the AVM. Blood products are visible on sagittal MRI after embolization. At hospital discharge, her left-sided weakness had resolved, and her neurological examination was normal. The hydrocephalus had resolved.

The Surgical Histopathology of the Filum Terminale: Findings from a Large Series of Patients with Tethered Cord Syndrome

This study investigated the prevalence of embryonic and connective tissue elements in the filum terminale (FT) of patients with tethered cord syndrome (TCS), examining both typical and pathological histology. The FT specimens from 288 patients who underwent spinal cord detethering from 2013 to 2021 were analyzed. The histopathological examination involved routine hematoxylin and eosin staining and specific immunohistochemistry when needed. The patient details were extracted from electronic medical records. The study found that 97.6% of the FT specimens had peripheral nerves, and 70.8% had regular ependymal cell linings. Other findings included ependymal cysts and canals, ganglion cells, neuropil, and prominent vascular features. Notably, 41% showed fatty infiltration, and 7.6% had dystrophic calcification. Inflammatory infiltrates, an underreported finding, were observed in 3.8% of the specimens. The research highlights peripheral nerves and ganglion cells as natural components of the FT, with ependymal cell overgrowth and other tissues potentially linked to TCS. Enlarged vessels may suggest venous congestion due to altered FT mechanics. The presence of lymphocytic infiltrations and calcifications provides new insights into structural changes and mechanical stress in the FT, contributing to our understanding of TCS pathology.

Autoimmune glial fibrillary acidic protein astrocytopathy complicated with low flow perimedullary arteriovenous fistula: a case report

Autoimmune glial fibrillary acidic protein (GFAP) astrocytopathy and low-flow perimedullary arteriovenous fistulas (PMAVFs) may cause longitudinal widespread myelopathy. We report a middle-aged male patient with autoimmune GFAP astrocytopathy complicated with low flow PMAVFs disease, presenting with lower extremity weakness and dysuria. Magnetic resonance imaging (MRI) of the spinal cord revealed a significant longitudinal extent of T2 high signal from T11 to L1, with the lesion located proximal to the vascular territory supplied by the anterior spinal artery. Multiple patchy abnormal signals were seen adjacent to the anterior and posterior horns of the lateral ventricles bilaterally and at the centers of the semi-ovals on MRI of the cranial brain, with iso signal in T1Flair, the high signal in T2WI, and no high signal seen in Diffusion Weighted Imaging (DWI). Subsequently, the presence of anti-GFAP antibodies was detected in the cerebrospinal fluid (CSF), and the diagnosis of autoimmune GFAP astrocytopathy in conjunction with low-flow PMAVFs was confirmed through spinal digital subtraction angiography (DSA). This case report aims to increase neurologists' awareness of this disease and avoid missed or misdiagnosed cases that may lead to delayed treatment.

CyberKnife Radiosurgery for Spinal Intramedullary Arteriovenous Malformations: A Single-Center Experience

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.

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.

Foix-Alajouanine Syndrome: A Case Report

Foix-Alajouanine syndrome is a rare form of presentation of an arteriovenous malformation of the spinal cord that causes myelopathy in the thoracic and lumbar medullary segments. We present the case of a 46-year-old female who suffered from weakness in the lower limbs with sensation loss, low back pain, urinary incontinence, and constipation. The magnetic resonance image T2 sequence of the thoracic spine from T6 to T11 revealed abnormally hypointense signals in the posterior epidural region caused by larger arteries. A spinal digital subtraction angiography was useful to diagnose a right perimedullary fistula with venous drainage, which was satisfactorily embolized. The key to suspecting this diagnosis is the presence of dilated vessels in the posterior epidural space, which are evident in T2 and short tau inversion recovery (STIR)-weighted sequences. Physicians often misdiagnose Foix-Alajouanine syndrome, resulting in potential delays in care. Neurosurgeons can use surgery or endovascular embolization to treat this condition.

Filar arteriovenous fistula mimicking upper motor neuron palsy: A case report with review of the literature

Background:

Filar A-V fistula is a rare entity. It requires a high degree of suspicion to diagnose. Magnetic resonance imaging (MRI) findings are often nonspecific and spinal angiogram is required to diagnose it.

Case Description:

A 63-year-old male patient presented with Grade 4 spastic paraplegia and significant sensory disturbance below D8 level along with severe vesicorectal dysfunction. On imaging flow voids were present at lower dorsal and lumbar level in MRI (T2 sequence). Patient underwent spinal digital substraction angiography (DSA) which was suggestive of filar fistula at L4-L5 level. Patient underwent surgical exploration with L4-5 laminectomy. Feeding artery was identified using indigocyanine green (ICG) dye and excised along with filum and dilated vessels. Patient recovered symptomatically in postoperative period.

Conclusion:

Filar fistula is a rare lesion and it presents with long standing progressive congestive myelopathy. It requires a high degree of suspicion to diagnose it. DSA is the gold standard for diagnosis and management planning. Surgical approach utilizing the ICG dye is best treatment options in such cases.

[Spinal arteriovenous malformations]

Spinal vascular malformations include various entities such as spinal arteriovenous malformations (AVM) and represent a rare disease. Patients may present with acute or progressive sensorimotor deficits and/or nonspecific symptoms such as hypoesthesia or paresthesia, diffuse back and muscle pain, or feelings of weakness. When spinal arteriovenous malformation is suspected, magnetic resonance imaging (MRI) is the first diagnostic step to rule out other differential diagnoses, followed by a selective spinal angiography. Therapeutic options include endovascular therapy by embolization and/or surgical resection. If spinal AVM is treated properly, a significant reduction in symptoms can be achieved.

Spinal Vascular Shunts: Single-Center Series and Review of the Literature of Their Classification

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.

Minimally invasive microsurgical treatment of spinal dural arteriovenous fistula: how I do it

BACKGROUND

Spinal dural arteriovenous fistula (d-AVF) is the most common spinal vascular malformations. Management includes endovascular embolization, and/or surgical obliteration of the shunt.

METHOD

Applied to spinal d-AVF, mini-invasive surgical (MIS) obliteration is described as a mini-open approach using Mast Quadrant™ system. Important anatomical landmarks are reviewed. Indications, advantages, and limitations are discussed, and a step-by-step description of the procedure is presented.

CONCLUSION

MIS is a good solution to treat d-AVF with a good outcome.

The utility of intraoperative neurophysiological monitoring in surgical treatment for spinal arteriovenous malformations: a historical control study

•

Postoperative neurological complications are not rare in surgical treatment for spinal arteriovenous malformations (SAVMs).

•

An in-group analysis showed that the accuracy of IONM for detecting postoperative neurological complications was relatively high.

•

Multimodal IONM may reduce postoperative neurological complications in the surgical treatment for SAVMs.

Objective

Methods

Results

Conclusions

Significance

Spinal Vascular Shunts: A Patterned Approach

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.

Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend?

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.

The Accuracy of the TRICKS MRI in Diagnosing and Localizing a Spinal Dural Arteriovenous Fistula: A Feasibility Study

OBJECTIVE

Spinal vascular malformations (SVMs) are a heterogenous group of vascular abnormalities. The gold standard for diagnosis of SVMs is spinal digital subtraction angiography (DSA), which can be challenging because of the large number of segmental arteries that need to be catheterized and the limitations in term of contrast volume used and fluoroscopy time. We describe and compare the use of the time-resolved imaging of contrast kinetics (TRICKS) sequence and DSA in the diagnosis of spinal dural arteriovenous fistulas (SDAVFs) in our institution.

METHODS

This is a retrospective cohort study of 27 patients who had a TRICKS MRI followed by a DSA for the diagnosis of their SDAVFs between November 2003 and November 2021.

RESULTS

A total of 19 (70.4%) patients were positive for a SDAVF on both TRICKS MRI and DSA. Out of those 19, 9 (47.4%) were in the exact location on both TRICKS MRI and DSA whereas 10 (52.6%) were in different locations. With respect to the 10 patients who had discrepancies in their SDAVF localization between the 2 modalities, 9 (90%) patients had a 1-level difference and 1 (10%) had a 2-level difference.

CONCLUSIONS

TRICKS MRI represents an accurate screening tool to be performed before a spinal DSA in order to guide the interventionalist to focus on the correct level ±2 levels; this extra noninvasive screening tool will decrease the risk of a kidney injury from an overuse of contrast and minimize the fluoroscopy/radiation overexposure.

Rapid Progression to Complete Paraplegia After Electroacupuncture in a Patient With Spinal Dural Arteriovenous Fistula: A Case Report

Spinal dural arteriovenous fistula (SDAVF) usually has an insidious clinical course, but 5–15% of the cases have acute exacerbations. In some cases, there is an abrupt progression to paraplegia following an epidural injection or anesthesia. Electroacupuncture is a form of acupuncture that applies a small electrical current to needles inserted at specific points in the body. It is widely used for its analgesic effect on back pain. In this study, we report a rare case of SDAVF in which the symptoms of a patient worsened rapidly to complete paraplegia within a few hours after applying electroacupuncture to his back. A 49-year-old man had rapid progression to complete paraplegia within a few hours of electroacupuncture on his back. MRI showed SDAVF and worsening of cord signal change. An emergency operation was performed to ligate the SDAVF. The patient was able to walk 1 month post-operatively. Most of the neurological deficits had disappeared by 1 year post-operatively, with normalization of MRI. Our case emphasizes that SDAVF patients should be careful when exposed to any circumstances that might affect the circulation around the dural arteriovenous fistula, such as electroacupuncture. Patients should also be warned in advance about the possibility of rapid exacerbation of neurological symptoms. Regardless of the severity of the neurological symptoms, immediate treatment is essential for recovery and a better outcome.

The efficacy and deficiency of contemporary treatment for spinal cord arteriovenous shunts

Contemporary treatments for spinal cord arteriovenous shunts are only based on clinicians' treatment experiences and expertise due to its rarity. We reviewed the clinical course of the largest multi-cantered cohort to evaluate the efficacy and deficiency of contemporary interventional treatments for spinal cord arteriovenous shunts. The clinical features, treatment results and clinical outcomes of 463 spinal cord arteriovenous shunts patients were retrospectively assessed. The main outcome was the neurological deterioration that was evaluated based on the modified Aminoff and Logue scale. According to post-treatment DSA, complete obliteration was defined as disappearance of the intradural lesion, whereas partial obliteration was defined as any residual intradural lesion remaining visible and was further categorized as shunt-reduction obliteration (the nidus or shunt points was reduced) or palliative obliteration (only obliterated aneurysms or feeders). Cure rate was 40.6% for whole cohort, 58.5% after microsurgery, and 26.4% after embolization. The curative resection was associated with non-metameric lesions, lesions with a maximum diameter < 3 cm and lesions without anterior sulcal artery supply. The curative embolization was associated with fistula-type lesions, non-metameric lesions, and main drainage diameter < 1.5 mm. Permanent treatment-related neurological deficits rate was 11.2% for the whole cohort, 16.1% after microsurgery, and 5.6% after embolization. The pre-treatment clinical deterioration rate was 32.5%/year, which decreased to 9.3%/year after clinical interventions. After partial treatment, the long-term acute and gradual deterioration rate were 5.3%/year and 3.6%/year, respectively. The acute deteriorations were associated with metameric lesions, craniocervical lesions, lesions with a maximum diameter ≥2 cm and residual aneurysm. Residual aneurysm was the only predictor of acute deterioration for non-metameric spinal cord arteriovenous shunts. The gradual deteriorations were associated with palliative obliteration, absence of pre-treatment acute deterioration and intact main drainage. Although clinical risks of spinal cord arteriovenous shunts were reduced after clinical interventions, contemporary treatments for spinal cord arteriovenous shunt remains associated with considerable risks and incomplete efficacy. Individualized treatment plans should be adopted according to the angioarchitectural features and major clinical risks of specific lesions. There is a higher opportunity for complete obliteration for lesions with simple angioarchitecture. However, regarding most of spinal cord arteriovenous shunts with complex vascular anatomy, partial treatment is the only choice. For these patients, palliative obliteration targeting the aneurysms is recommended for reducing hemorrhagic risk, whereas shunt-reduction obliteration is necessary for non-haemorrhagic myelopathy. Contemporary treatment is ineffective in reducing hemorrhagic risk of incurable metameric spinal cord arteriovenous shunts.

Spinal Arteriovenous Malformation: Case Report and Review of the Literature

Spinal arteriovenous malformations (AVMs) are a rare form of spinal blood vessel defect that results in vessel engorgement leading to clinical signs secondary to mass effect and ischemia. We present the patient’s clinical course following suspicion of spinal AVM along with a review of current classification and imaging modalities.

Microsurgical or endovascular strategy for complete obliteration of spinal arteriovenous shunts in a single-institute 10-year retrospective study

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.

Pediatric spinal cord infarction following a minor trauma: a case report

INTRODUCTION

Pediatric spinal cord infarction is a rare entity that presents a diagnostic challenge at the emergency department. Ischemic spinal cord infarction can occur in the setting of trauma, cardiovascular malformation, or postoperatively. We report a case of anterior spinal artery infarction following seemingly minor trauma in an otherwise healthy 14-year-old male.

CASE PRESENTATION

A 14-year-old male presented with unprovoked sudden-onset stabbing back pain earlier that day. The patient then demonstrated bilateral lower extremities weakness while at the emergency department. After extensive diagnostic workup, the patient was diagnosed with anterior spinal artery territory infarction involving the thoracic spinal cord. Minor trauma to the thoracic spinal cord was detected on imaging and was believed to be the culprit of this event.

DISCUSSION

Given the rarity of spinal cord ischemia, a high index of suspicion and extensive workup of patients presenting with clinical weakness are needed for accurate diagnosis and to avoid the eventual poor outcome. With so few reports in the literature regarding spinal cord ischemia in the pediatric population, accurate diagnosis is often delayed until after irreversible events have already taken place. Our case report of anterior spinal artery distribution thoracic cord infarct following a minor trauma was diagnosed by axial thin-slice DWI MRI with an otherwise negative workup.

A rare case of a cervical dural arteriovenous fistula presenting in a younger patient with vertex subarachnoid hemorrhage: Case report and literature review

Spinal dural arteriovenous fistulas (SDAVF) are rare entities, which mainly occur in the thoracic and lumbar regions of older adults with a significant male predominance. The clinical manifestations are nonspecific such as myelopathy and this can make it challenging to diagnose. Rarely these have been described in the cervical region with even rare manifestations including subarachnoid hemorrhage. In the few reports of hemorrhage, it is usually infratentorial. We present a case of 40-year-old female (uncommon gender and younger age) who presented with headaches and was found to have supra tentorial subarachnoid hemorrhage and a suspicious lesion in the spinal canal. This proved to be a type 1 AVM of the spinal canal (per the American British and French classification). This was successfully treated endovascularly. With the discussion of the relevant literature we hope that this case can add to our medical knowledge as another presentation of this uncommon condition and ultimately help in diagnosing this illusive and rare entity.

Monitoring Arteriovenous Malformation Response to Genotype-Targeted Therapy

Arteriovenous malformations (AVMs) have recently been reported to have a high incidence of somatic KRAS mutations suggesting potential for treatment with mitogen-activated protein kinase inhibitors. In this case report, we describe genotype-targeted treatment of a KRAS mutant metameric AVM in a patient with Cobb syndrome using the mitogen-activated protein kinase inhibitor trametinib. Therapeutic response was monitored with phase-contrast magnetic resonance angiography to quantify AVM arterial inflow as an imaging biomarker. Treatment with trametinib resulted in a substantial decrease in blood flow to the AVM, with a >75% reduction in arterial inflow after 6 months of trametinib therapy.

Management of spinal dural arteriovenous fistula in a child with myelopathy

Background:

Spinal dural arteriovenous fistulas (DAVF) are rare intradural spinal lesions. Patients with DAVF are typically in the 40’s or 50’s, and classically present with acute neurological deterioration. Notably, these lesions are exceedingly rare in the pediatric age group.

Case Description:

A 2-year-old child presented with the sudden onset of lethargy, and 4/5 weakness of the left lower extremity with accompanying ataxia. The cervicothoracic MR scan revealed central cord edema from C5 to T4. A DAVF was diagnosed based on the multiple dilated intradural perimedullary veins. Following endovascular treatment, the child markedly recovered and remained stable 2 years later.

Conclusion:

DAVFs are treatable lesions that rarely occur in the pediatric age group. They are associated with serious neurological morbidity. When suspected, they should be immediately diagnosed with magnetic resonance imaging/magnetic resonance angiography, and formal angiography. Prompt neurosurgical and neuroradiological/ endovascular opinions and intervention should be sought to provide and the best treatment strategy.

Cervical spinal arteriovenous fistula with ventral perimedullary venous drainage

BACKGROUND

Spinal arteriovenous fistula (AVF) represents the most common type of spinal vascular lesions and is often associated with progressive neurological dysfunction.

METHOD

Here, we present a unique case of a spinal vascular malformation that does not fit the traditional classification schemes. The patient presented with progressive neurologic deficits resembling partial Brown-Sequard syndrome and was subsequently found to have a lesion resembling type I spinal AVF. However, this intradural fistula drained into the ventral venous plexus rather than dorsal.

CONCLUSION

Recognizing these rare anatomical variants is paramount in achieving successful obliteration and improved functional outcome for patients.

Intraoperative Neurophysiologic Monitoring Correlates with Neurologic Outcome After Endovascular and Surgical Treatment of a Cervical Arteriovenous Malformation

BACKGROUND

 The treatment of spinal intramedullary arteriovenous malformations (AVMs) presents the risk of spinal cord ischemia because of the vascular nidus and their feeding arteries involving and supplying the spinal cord parenchyma. The multimodal approach includes endovascular embolization and microsurgical excision, both benefiting from intraoperative neurophysiologic monitoring. We present a case study of a patient who underwent several staged embolizations and open surgery for microsurgical excision.

PATIENT

 A 32-year-old man who presented with a recurrent glomus-type intramedullary AVM in the cervical spinal cord, located at the C5-C6 segment, with progressive neurologic deterioration.

METHODS

 Somatosensory evoked potentials (SEPs) and transcranial motor evoked potentials (MEPs) were performed during three embolizations, a provocative test, and surgery, in addition to D-wave during microsurgical excision.

RESULTS

 Abolished hand MEP and drop in SEP during a provocative test guided the surgeon to embolize from a safer vessel with no acute neurologic deficit after three embolizations. Before surgery, an angiography showed the left posterior spinal artery supplying the AVM. After resecting the vascular nidus from the spinal parenchyma, left-hand MEP decreased in amplitude and later abolished, and SEP decreased. Interestingly, no D-wave or distal MEPs were affected. Weakness in the left hand immediately and 2 weeks postoperatively advocates for metameric spinal cord ischemia with preservation of long spinal cord pathways.

CONCLUSIONS

 Intraoperative neurophysiologic monitoring correlates with neurologic outcome after endovascular and surgical treatment of a cervical AVM. Intraoperative monitoring provides continuous functional information of long and metameric spinal cord pathways, which is critical when deciding on the vessel to be embolized and during microsurgical excision where the surgeon is in less control of the AVM hemodynamic flow.

Anterior Cervical Pial Arteriovenous Malformation Associated with a Spinal Aneurysm: Case Report and Review of the Literature

BACKGROUND

Cervical pial arteriovenous malformation (AVM) is an extremely rare condition that can present with progressive myelopathy or acute hemorrhage (subarachnoid or intramedullary). The classification process is still a topic of discussion, given the limited number of cases described, as well as correct therapeutic management. Here, we present a case of a young female with anterior cervical pial AVM associated with spinal aneurysm.

CASE DESCRIPTION

A 31-year-old female in the fifth month of pregnancy presented to the emergency department for tetraparesis, sphincter disturbances, and burning dysesthesia. Through magnetic resonance angiography, a cervical pial arteriovenous malformation (AVM) with a spinal aneurysm has been diagnosed. After a multidisciplinary consult, a neurosurgical approach has been proposed to minimize the hemorrhagic risk. A laminectomy C2-C4 level was performed, followed by identification of the AVM on the anterior-lateral left-sided surface of the spinal cord. The lesion was associated with a thrombosed aneurysm at the C2 level. Using neurophysiologic monitoring, we performed a temporary clipping of afferent vessels to the AVM. The thrombosed aneurysm was removed. Indocyanine green fluorescein and intraoperative Doppler confirmed complete resolution of AVM. The postoperative course has been regular with no complications recorded.

CONCLUSIONS

Surgical procedure with perioperative neuromonitoring is an effective way to treat anterior cervical pial AVM associated with spinal aneurysm. A multidisciplinary approach is always suggested.

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.

Neuroendovascular surgery

Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.

Adult Spinal Arteriovenous Malformations: Natural History and a Multicenter Study of Short-Term Surgical Outcomes

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.

Spinal Vascular Malformations: Treatment and Outcome

BACKGROUND

Vascular malformations of the spinal cord are a rare and complex clinical entity and can lead to severe morbidity with progressive spinal cord symptoms if not treated properly. In early stages, the disease is characterized by slowly progressive, nonspecific symptoms, such as gait disturbance, paresthesia, diffuse sensory symptoms, and radicular pain; in the late stages, bowel and bladder incontinence, erectile dysfunction, and urinary retention may develop. In recent decades, understanding and treatment of spinal vascular malformations have improved with the evolution of diagnostic tools and treatment modalities; however, it is still difficult to manage these cases because of the complexity of the pathology. The aims of this study were to present the long-term outcomes of our patients and to discuss the optimal management strategies.

METHODS

We reviewed the records of 78 patients with spinal vascular malformations and performed a retrospective, single-center case series evaluating initial occlusion, recanalization, retreatment, and neurologic status of patients with dural arteriovenous fistulas, perimedullary arteriovenous fistulas, arteriovenous malformations, and extradural arteriovenous fistulas who had undergone embolization and/or surgery.

RESULTS

No mortality was observed. Complete obliteration was achieved in 76 patients (97.4%).

CONCLUSIONS

Both endovascular and surgical treatment of spinal vascular malformations resulted in significant long-term recovery from myelopathic symptoms and improvement in quality of life for most patients.

Natural history of spinal cord arteriovenous shunts: an observational study

The natural history of intradural spinal cord arteriovenous shunts is unknown. We performed an observational study in a consecutive patient cohort with symptomatic intradural spinal cord arteriovenous shunts who were admitted to three institutes to investigate the clinical course of this complex disease, which would provide valuable evidence to inform clinical decision-making. The clinical course of patients with symptomatic intradural spinal cord arteriovenous shunts from initial presentation to occurrence of clinical deterioration, initiation of treatment, or last follow-up was analysed. Patients with at least 1 month of observation were included in this study. Clinical onset and deterioration patterns were divided into acute and gradual. Annual and cumulative rates of clinical deterioration as well as their risk factors were analysed using Kaplan-Meier life table analysis and Cox proportional hazards model. To assess risks and benefits of treatment, post-treatment clinical courses were further assessed. Four hundred and sixty-six patients with a mean observational period of 36.9 ± 58.8 months were included; 56.7% of patients presented with acute onset, of whom 77.3% experienced spontaneous recovery. Age of onset older than 28 years, initial modified Aminoff and Logue scale of >3, mid-thoracic lesions and non-ventral lesions were independent predictors of failure for spontaneous recovery. The annual risk of general, acute and gradual clinical deterioration after onset was 30.7%, 9.9% and 17.7%, respectively. Risk of deterioration was highest in the early period after initial onset. Acute onset was the only independent risk factor [hazard ratio 1.957 (95% confidence interval, CI 1.324–2.894); P = 0.0008] of acute deterioration and gradual onset was the strongest predictor [hazard ratio 2.350 (95% CI 1.711–3.229); P < 0.0001] of the gradual deterioration among all the stratifying factors. After invasive treatment, complete obliteration was achieved in 37.9% of patients (138 of 364) and improved or stable clinical status was noted in 80.8% of patients. Forty-two patients (11.5%) experienced permanent complications. Overall post-treatment deterioration rate was 8.4%/year, and 5.3%/year if permanent complications were excluded. The natural history of symptomatic spinal cord arteriovenous shunts is poor, especially in the early period after onset, and early intervention is thus recommended. Initial onset pattern significantly affects the natural history of the lesion, which prompts a differentiated treatment strategy.

Type I AV fistula of the thoracic spinal cord

Type I AV fistulas of the spinal cord are exceedingly rare. The average age at diagnosis is 50. Clinical presentation is often very non-specific, and sensory deficits and sphincter dysfunction may also occur. Neurological deterioration is generally gradual. Thus, failure to diagnosis frequently results in permanent disability. A 22-year-old female complained of a "muscle spasm" in the midline thoracic area with no history of trauma or prior occurrence. She also experienced bilateral lower extremity weakness/numbness and perianal anesthesia. She is a healthy female with no medical problems. Exam revealed lower extremity motor function of 1/5 as well as diminished sensation. A foley catheter was placed for urinary retention. The remainder of the neurological exam was normal. MRI demonstrated a lesion at the fourth thoracic level with significant cord compression. The patient was taken emergently to the operating room by neurosurgery. This case demonstrates a rare disorder occurring in a 22-year old female, far younger than the typical 50-year old patient. Moreover, the lesion was located in the thoracic rather than the typical lumbar cord. Symptoms may be misinterpreted as a peripheral nerve lesion and delay time to diagnosis. Early diagnosis remains critical to prevent permanent neurologic sequelae. AV fistula should remain high on the differential of patients presenting with back pain and focal neurologic complaints.

Quantitative protein profiling and pathway analysis of spinal arteriovenous malformations

Spinal arteriovenous malformations (sAVM) are rare and heterogeneous group of blood vessel disorders that affect spinal cord function directly or indirectly; however, the pathogenesis of sAVM is still unclear. In this study, we compared four sAVM specimens obtained during surgery and donated control samples in a Tandem Mass Tag (TMT)-labeled proteomic analysis. We identified 3101 proteins, 654 of which were differentially expressed in sAVM samples compared with the controls. Of these, 96 proteins were upregulated and 358 proteins were downregulated. Gene ontology (GO) analysis revealed that extracellular matrix organization in the biological process category and integrin-binding proteins in the molecular function category were the most enriched items. Two significant differentially expressed proteins (MYLK and MMP9) were verified by Western blot analysis. The pathway analysis indicated that the differentially expressed proteins in the pathways of angiogenesis, focal adhesion and cytoplasmic ribosome contributed to sAVM. The changes in protein profiles identified in this proteomic study provide an improved understanding of the pathogenesis of sAVM. The proteomics data are available via ProteomeXchange with identifier PXD007982.

Stereotactic Radiotherapy for Intramedullary Spinal Arteriovenous Malformations

Introduction Preliminary results of stereotactic radiotherapy (SRT) for spinal arteriovenous malformation (AVM) in five cases are presented.  Methods Two cases were male and three were female. Their median age was 32 years (range: 23 to 54 years). The spinal intramedullary AVMs were located in the cervical spine in three and in the thoracic spine in two. SRT with 20 Gy in four fractions was delivered to the nidus in every case. Results At the end of the median follow-up period of 5.5 years (range: 3 to 8.5 years), the neurological symptoms and signs were improved or unchanged as compared with before treatment, although a temporary adverse effect developed between a half year and one year after SRT in one case. The nidi were obliterated five and a half years after SRT in one case and three years after SRT in one. In the other three cases, the nidi were unchanged. Conclusion SRT with 20 Gy in four fractions was thought to be a safe treatment, though this study dealt with only a small number of patients with a short-term follow-up period.