Spinal intradural perimedullary arteriovenous fistula with varix in infant

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Spinal arteriovenous shunts presenting before 2 years of age: analysis of 13 cases

BACKGROUND AND PURPOSE

A minority of patients with spinal arteriovenous malformations (SAVM) are symptomatic as neonates or infants. We analyzed the clinical and anatomic factors associated with this early presentation, and reviewed our experience in treating patients with these lesions.

METHODS

A retrospective review of clinical records and imaging studies was performed for patients with SAVM who presented at less than 2 years of age and who were examined by the diagnostic and interventional neuroradiology service at our institution. Clinical, imaging and treatment data had been entered prospectively into a department database.

RESULTS

Thirteen patients were identified that had SAVMs that were either diagnosed or that became symptomatic before 2 years of age (nine boys, four girls). These represented 13% of the SAVM seen during the same period of time. The mean age at presentation was 6.9+/-6.4 months. Of the 13 patients, 11 had neurologic symptoms attributable to the spinal lesion. The presentation was nonhemorrhagic in ten patients and associated with hemorrhage in three. Ten lesions were fistulas [spinal cord arteriovenous fistulas (SCAVFs)] (77%); two were of the nidus type of malformation. There were syndromic associations in eight patients: hereditary hemorrhagic telangectasia (HHT) in six patients, all but one of these lesions were intradural high-flow perimedullary SCAVFs (46% of overall SAVM and 56% of SCAVF), and spinal arteriovenous metameric syndrome in two patients. One patient had Hirschprung's anomaly. Eight patients underwent endovascular treatment alone, one had surgery and embolization, and four were not treated. In all patients undergoing embolization, n-butyl cyanoacrylate liquid adhesive was used. Of those patients who underwent endovascular treatment, the lesion was completely obliterated in 7 and a 90% reduction in nidal size was achieved in the remaining 2. There was one treatment complication (infection) which resolved with medical therapy. No procedure-related permanent morbidity or mortality was seen. Follow-up data were available (mean 31.4 months) in ten patients (nine treated). All treated patients were either stable or improved, with none showing further deterioration following treatment.

CONCLUSION

Factors associated with early presentation in neonates and infants with spinal arteriovenous shunts include the presence of high-flow, solitary fistulas and HHT. Specifically, the presence of SCAVF in a child less than 2 years of age is highly suggestive of HHT. Despite the aggressive nature of these lesions, many are amenable to endovascular treatment, and this is associated with a favorable posttreatment course in most cases.