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Shapiro M, Nossek E, Sharashidze V, Tanaka M, Rutledge C, Chung C, Khawaja A, Riina H, Nelson PK, Raz E. Spinal dural and epidural fistulas: role of cone beam CT in diagnosis and treatment. J Neurointerv Surg 2024; 16:615-623. [PMID: 37673678 DOI: 10.1136/jnis-2022-019950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/14/2023] [Indexed: 09/08/2023]
Abstract
Understanding normal spinal arterial and venous anatomy, and spinal vascular disease, is impossible without flow-based methods. Development of practical spinal angiography led to site-specific categorization of spinal vascular conditions, defined by the 'seat of disease' in relation to the cord and its covers. This enabled identification of targets for highly successful surgical and endovascular treatments, and guided interpretation of later cross-sectional imaging.Spinal dural and epidural arteriovenous fistulas represent the most common types of spinal shunts. Although etiology is debated, anatomy provides excellent pathophysiologic correlation. A spectrum of fistulas, from foramen magnum to the sacrum, is now well-characterized.Most recently, use of cone beam CT angiography has yielded new insights into normal and pathologic anatomy, including venous outflow. It provides unrivaled visualization of the fistula and its relationship with spinal cord vessels, and is the first practical method to study normal and pathologic spinal veins in vivo-with multiple implications for both safety and efficacy of treatments. We advocate consistent use of cone beam CT imaging in modern spinal fistula evaluation.The role of open surgery is likely to remain undiminished, with increasing availability and use of hybrid operating rooms for practical intraoperative angiography enhancing safety and efficacy of complex surgery.
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Affiliation(s)
- Maksim Shapiro
- Department of Radiology, Neurosurgery, and Neurology, New York City Health and Hospitals Bellevue, New York, New York, USA
| | - Erez Nossek
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Neurosurgery, NYC Health Hospitals Bellevue, New York, New York, USA
| | - Vera Sharashidze
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Radiology, NYC Health Hospitals Bellevue, New York, New York, USA
| | - Michihiro Tanaka
- Department of Neurosurgery, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Caleb Rutledge
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, USA
- Department of Neurosurgery, NYC Health Hospitals Bellevue, New York, New York, USA
| | - Charlotte Chung
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Radiology, NYC Health Hospitals Bellevue, New York, New York, USA
| | - Ayaz Khawaja
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Radiology, NYC Health Hospitals Bellevue, New York, New York, USA
| | - Howard Riina
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, USA
| | - Peter Kim Nelson
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Radiology, NYC Health Hospitals Bellevue, New York, New York, USA
| | - Eytan Raz
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Radiology, NYC Health Hospitals Bellevue, New York, New York, USA
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Beaman C, Molaie A, Ghochani Y, Fukuda K, Peterson C, Kaneko N, Nour M, Szeder V, Colby GP, Tateshima S, Jahan R, Duckwiler G. Clinical presentation and treatment of 26 spinal epidural arteriovenous fistulas: a single-center experience. J Neurointerv Surg 2024:jnis-2024-021471. [PMID: 38569885 DOI: 10.1136/jnis-2024-021471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Spinal epidural arteriovenous fistulas (SEDAVFs) are rarely diagnosed vascular malformations that can cause spinal cord compression and congestive myelopathy. METHODS This is a single-center, retrospective case series of patients with SEDAVFs who underwent observation or treatment at UCLA medical center between 1993 and 2023. RESULTS Between 1993 and 2023 a total of 26 patients at UCLA were found to have a SEDAVF. The median age at treatment was 59 years (range 4 months to 91 years). Compared with sacral, lumbar, and thoracic SEDAVFs, patients with cervical SEDAVF were younger (41 years vs 63 years, P=0.016) and more likely to be female (66.7% vs 14.3%, P=0.006). Possible triggers for development of SEDAVFs may be prior spinal surgery or trauma (n=4), turning the neck (n=1), lifting a heavy box (n=1), a prolonged period of bending over (n=1), and neurofibromatosis type 1 (n=1). Of the 22 patients treated endovascularly, 18 (82%) were angiographically cured on the first attempt without complications. One patient underwent surgical treatment alone and had a failed surgery on the first attempt, and developed a surgical site infection after the second successful attempt at treatment. Of the 16 patients with adequate clinical follow-up, 11 (69%) demonstrated early improved clinical outcome (eg, improved strength on examination, absent bruit). CONCLUSIONS SEDAVFs are a rarely diagnosed disease that can be treated effectively and safely with endovascular embolization in most cases. Patients with sacral, lumbar, and thoracic SEDAVFs were older and more often male compared to patients with cervical SEDAVFs.
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Affiliation(s)
- Charles Beaman
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Amir Molaie
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Yasmin Ghochani
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Keiko Fukuda
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Catherine Peterson
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Naoki Kaneko
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - May Nour
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Viktor Szeder
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Geoffrey P Colby
- Departments of Neurosurgery and Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Satoshi Tateshima
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Reza Jahan
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
| | - Gary Duckwiler
- Department of Radiology, UCLA Medical Center, Los Angeles, California, USA
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Jadhav AP. Vascular Myelopathies. Continuum (Minneap Minn) 2024; 30:160-179. [PMID: 38330477 DOI: 10.1212/con.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. LATEST DEVELOPMENTS Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. ESSENTIAL POINTS Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.
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Takai K, Endo T, Fujimoto S. Angiographic challenges of spinal dural and epidural arteriovenous fistulas: report on 45 cases. Neuroradiology 2024; 66:279-286. [PMID: 37792087 DOI: 10.1007/s00234-023-03227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE The localization of the fistula level in spinal dural arteriovenous fistulas (dAVFs) and epidural arteriovenous fistulas (edAVFs) remains a diagnostic challenge. METHODS Consecutive patients with spinal dAVFs and edAVFs in the thoracic, lumbar, and sacral regions were included. The primary endpoint was to describe the characteristics of patients who required angiography with multiple catheterizations of segmental arteries (10 or more). RESULTS Forty-five patients (median age 69 years; male 89%; dAVFs, n = 31; edAVFs, n = 14) were included. Spinal dAVFs commonly developed in the thoracic region and edAVFs in the lumbosacral region. Fistulas were predicted at the correct level or plus/minus 2 level in less invasive examinations using multi-detector CT angiography (n = 28/36, 78%) and/or contrast-enhanced MR angiography (n = 9/14, 64%). We encountered diagnostic challenges in the localization of fistulas in 6 patients. They underwent angiography a median of 2 times. In each patient, spinal levels were examined at a median of 25 levels with a median radiation exposure of 3971 mGy and 257 ml of contrast. Fistulas were finally localized at the high thoracic region (T4-6) in 3 patients, the sacral region (S1-2) in 2, and the lumbar region (L3) in 1. Four patients were diagnosed with edAVFs and 2 with dAVFs. The correlation coefficient between the fistula level and the rostral end of the intramedullary T2 high-signal intensity on MRI was interpreted as none. CONCLUSION In patients in whom less invasive examinations failed for fistula localization, high thoracic or sacral AVFs need to be considered.
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Affiliation(s)
- Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo, 183-0042, Japan.
| | - Takeaki Endo
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo, 183-0042, Japan
| | - So Fujimoto
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo, 183-0042, Japan
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Harada T, Fujita A, Kohta M, Sasayama T. Remote thoracic spinal cord hemorrhage caused by lumbar epidural arteriovenous fistula with perimedullary venous drainage. Neurochirurgie 2023; 69:101485. [PMID: 37708577 DOI: 10.1016/j.neuchi.2023.101485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Tomoaki Harada
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Vercelli GG, Minardi M, Bergui M, Zenga F, Garbossa D, Cofano F. Spinal dural and epidural arteriovenous fistula: Recurrence rate after surgical and endovascular treatment. Front Surg 2023; 10:1148968. [PMID: 37082364 PMCID: PMC10111007 DOI: 10.3389/fsurg.2023.1148968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/21/2023] [Indexed: 04/07/2023] Open
Abstract
IntroductionSpinal dural arteriovenous fistula consist of an heterogenous group of vascular malformation often causing severe neurological deficit due to progressive myelopathy. This type of malformation could be associated with subarachnoid or subdural hemorrhage inside the spinal canal. In the English literature surgical treatment is regarded as the best option if compared to endovascular procedure, being the latter associated with an increased risk of relapse despite its less invasiveness.MethodsIn this study a retrospective analysis of 30 patients with spinal dural and epidural fistula associated with perimedullary venous congestion was undertaken. The radiological and clinical presentation of each patient is analyzed, and the grade of myelopathy is classified through the mJOA score.ResultsA total number of 31 out of 41 collected procedures (22 surgery vs. 19 endovascular) were dural fistulas while the remaining 10 were classified as epidural. A 46% recurrence rate for endovascular treatment against 0% for surgical (p-value 0.004) was described for dural fistulas, while in the epidural fistula group the rate of recurrence was 80% and 20% respectively for endovascular and surgery treatment (p-value 0.6).DiscussionAccording to the results, surgical treatment could be considered as first-line treatment for spinal dural arteriovenous fistulas. Endovascular embolization can be proposed in selected cases, as a less invasive technique, for elderly patients or with important comorbidities. In spinal epidural arteriovenous fistulas, in view of the greater invasiveness of the surgical treatment and the non-significant difference in terms of recurrence risk between the two techniques, endovascular treatment could be proposed as a first choice treatment; in the event of a recurrence, a surgical intervention will instead be proposed in a short time.
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Affiliation(s)
- Giovanni Giulio Vercelli
- Department of Neurosurgery, Ospedale San Giovanni Bosco, Turin, Italy
- Correspondence: Giovanni Giulio Vercelli Massimiliano Minardi
| | - Massimiliano Minardi
- Department of Neurosurgery, University of Turin, Turin, Italy
- Correspondence: Giovanni Giulio Vercelli Massimiliano Minardi
| | - Mauro Bergui
- Unità di neuroradiologia, A.O.U. Citta della Salute e della Scienza di Torino, Turin, Italy
| | - Francesco Zenga
- Dipartimento di Neuroscienze e Salute Mentale, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Diego Garbossa
- Dipartimento di Neuroscienze e Salute Mentale, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Fabio Cofano
- Department of Neurosurgery, University of Turin, Turin, Italy
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Kathrani NV, Chauhan RS, Ramalingaiah AH, Saini J, Devi BI. Percutaneous Embolization of Spinal Epidural Arteriovenous Fistulae: Report of 2 Cases and Technical Considerations. J Vasc Interv Radiol 2023; 34:498-500.e3. [PMID: 36473613 DOI: 10.1016/j.jvir.2022.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 11/08/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Nihar V Kathrani
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Richa S Chauhan
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Arvinda H Ramalingaiah
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru- 560029, Karnataka, India.
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru- 560029, Karnataka, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru- 560029, Karnataka, India
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Shima S, Tanaka Y, Sato S, Niimi Y. Spinal epidural arteriovenous fistula with improved sphincter impairment detected by intraoperative neurophysiological monitoring. Surg Neurol Int 2022; 13:384. [PMID: 36128103 PMCID: PMC9479640 DOI: 10.25259/sni_592_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/06/2022] [Indexed: 11/12/2022] Open
Abstract
Background: A spinal epidural arteriovenous fistula (SEAVF) is a rare type of arteriovenous shunt that occurs mainly in the thoracic or lumbar spine. Patients with SEAVF develop motor/sensory disturbances of the lower extremities and sphincter dysfunction. Among these symptoms, sphincter impairments show less improvement than others, and its relevance to neurophysiological monitoring has not been documented. Case Description: A 77-year-old woman presented with progressive motor weakness and numbness in the lower extremities and urinary and fecal incontinence. Spinal magnetic resonance imaging showed spinal cord edema in Th5-Th11 and enlarged perimedullary veins. We performed spinal angiography and endovascular treatment under intraoperative neurophysiological monitoring (IOM), including sensory evoked potential (SEP), motor evoked potential (MEP), and bulbocavernosus reflex (BCR) monitoring. Diagnostic angiography revealed a SEAVF with perimedullary venous drainage fed by the left L2 segmental artery. The shunt was completely embolized using N-butyl-2-cyanoacrylate. Although SEP and MEP of the lower legs were recordable during treatment, anal MEP and BCR were not observed. The sphincter symptoms improved 1.5 years after the treatment. Follow-up angiography revealed no shunt recurrence and improved venous congestion. Anal MEP and BCR were detected during angiography, indicating neurophysiological improvement in sphincter function. The prolonged latency of the monitoring suggested a pudendal nerve injury. Conclusion: This case report first described improvement of the IOM correlated with the functional recovery of sphincters after embolization of a SEAVF. Follow-up neurophysiological monitoring is important to assess the functional recovery of the sphincter.
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Affiliation(s)
- Shogo Shima
- Department of Neurosurgery and Neuroendovascular Therapy, St. Luke’s International Hospital, Tokyo, Japan
| | - Yasuko Tanaka
- Department of Clinical Laboratory and Intraoperative Neurophysiology, St. Luke’s International Hospital, Tokyo, Japan
| | - Shinsuke Sato
- Department of Neurosurgery and Neuroendovascular Therapy, St. Luke’s International Hospital, Tokyo, Japan
| | - Yasunari Niimi
- Department of Neurosurgery and Neuroendovascular Therapy, St. Luke’s International Hospital, Tokyo, Japan
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Ehresman J, Catapano JS, Baranoski JF, Jadhav AP, Ducruet AF, Albuquerque FC. Treatment of Spinal Arteriovenous Malformation and Fistula. Neurosurg Clin N Am 2022; 33:193-206. [PMID: 35346451 DOI: 10.1016/j.nec.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
With the rapid advancements in endovascular therapy over previous decades, the treatment of spinal arteriovenous malformations (AVMs) continues to evolve. The decision to use endovascular versus surgical therapy largely depends on the type of lesion and its anatomic location. Recent studies demonstrate that endovascular treatment is effective for extradural arteriovenous fistulas (AVFs), intradural ventral (perimedullary) AVMs, and intramedullary spinal AVMs. Treatment of intradural dorsal (dural) AVFs remains largely surgical because of lower recurrence rates, although recent studies demonstrate equivocal outcomes. Extradural-intradural (juvenile) AVMs and conus AVMs remain difficult-to-treat lesions.
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Affiliation(s)
- Jeff Ehresman
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashutosh P Jadhav
- Department of Interventional Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA.
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The venous system during pregnancy. Part 1: physiologic considerations on the venous system. Int J Obstet Anesth 2022; 50:103273. [DOI: 10.1016/j.ijoa.2022.103273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/13/2022] [Accepted: 02/17/2022] [Indexed: 12/20/2022]
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Park D, Kim D, Kang DH, Lee S, Cho DC. Cervical Radiculopathy Caused by Spinal Epidural Arteriovenous Fistula (SEDAVF) Without Intradural Drainage: A Case Report and Literature Review. Korean J Neurotrauma 2022; 18:145-149. [PMID: 35557638 PMCID: PMC9064750 DOI: 10.13004/kjnt.2022.18.e11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/10/2022] [Accepted: 01/22/2022] [Indexed: 11/29/2022] Open
Abstract
Spinal epidural arteriovenous fistula (SEDAVF) is a rare vascular malformation. Due to the mass effect of enlarged epidural veins and venous hypertension, progressive radiculopathy and myelopathy are likely to occur. A 33-year-old female presented with right upper extremity weakness for a month. The cause of this symptom was a SEDAVF, which was located near the C5-6-7 foramens and compressed the nerve roots. In the absence of intradural venous drainage, endovascular treatment is often difficult because of the large venous pouch. We performed endovascular trapping of the vertebral artery (VA) and loose packing of the coil material on the AVF to minimize mass effects. Immediately after embolization, the fistula was occluded, but a small new feeder vessel developed a day later. An n-butyl cyanoacrylate embolization was performed, and the fistula was successfully occluded.
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Affiliation(s)
- Daewon Park
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Donghan Kim
- Department of Neurosurgery, ParkWeonWook Hospital, Busan, Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Subum Lee
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dae-Chul Cho
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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Al-Abdulwahhab AH, Song Y, Kwon B, Suh DC. Embolization Tactics of Spinal Epidural Arteriovenous Fistulas. Neurointervention 2021; 16:252-259. [PMID: 34425638 PMCID: PMC8561027 DOI: 10.5469/neuroint.2021.00220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/28/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Spinal epidural arteriovenous fistulas (SEDAVFs) show an epidural venous sac often with venous congestive myelopathy (VCM) due to intradural reflux at a remote level to which a transarterial approach would be difficult. We present 12 cases of SEDAVF with VCM and describe 3 main tactics for effective transarterial embolization. Materials and Methods Among 152 patients with spinal vascular malformations diagnosed in our tertiary hospital between 1993 and 2019, 12 SEDAVF patients with VCM were included. Three different transarterial embolization tactics were applied according to the vascular configuration and microcatheter accessibility. We evaluated treatment results and clinical outcomes before and after treatment. Results Transarterial embolization with glue (20–30%) was performed in all patients. The embolization tactics applied in 12 patients were preferential flow (n=2), plug-and-push (n=6), and filling of the venous sac (n=4). Total occlusion of the SEDAVF, including intradural reflux, was achieved in 11 (91.7%) of 12 patients, and partial occlusion was achieved in 1 patient. No periprocedural complications were reported. Spinal cord edema was improved in all patients for an average of 18 months after treatment. Clinical functional outcome in terms of the pain, sensory, motor, and sphincter scale and modified Rankin scores improved during a mean 25-month follow-up (6.3 vs. 3.3, P=0.002; 3.6 vs. 2.3, P=0.002, respectively). Conclusion Endovascular treatment for 12 SEDAVF patients with VCM achieved a total occlusion rate of 91.7% without any periprocedural complication. The combined embolization tactics can block intradural reflux causing VCM, resulting in overall good clinical outcomes.
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Affiliation(s)
- Abdulrahman Hamad Al-Abdulwahhab
- Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Diagnostic and Interventional Radiology Department, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al-Khobar City, Saudi Arabia
| | - Yunsun Song
- Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boseong Kwon
- Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Neurointervention Clinic, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Feng Y, Yu J, Xu J, He C, Bian L, Li G, Ye M, Hu P, Sun L, Jiang N, Ling F, Hong T, Zhang H. Natural History and Clinical Outcomes of Paravertebral Arteriovenous Shunts. Stroke 2021; 52:3873-3882. [PMID: 34412511 DOI: 10.1161/strokeaha.120.033963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Paravertebral arteriovenous shunts (PVAVSs) are rare. Whether the intradural venous system is involved in drainage may lead to differences in clinical characteristics through specific pathophysiological mechanisms. This study aims to comprehensively evaluate the natural history and clinical outcomes of PVAVSs with or without intradural drainage. METHODS Sixty-four consecutive patients with PVAVSs from 2 institutes were retrospectively reviewed. Lesions were classified as type A (n=28) if the intradural veins were involved in drainage; otherwise, they were classified as type B (n=36). The clinical course from initial presentation to the last follow-up was analyzed. RESULTS The patients with type A shunts were older at presentation (52.5 versus 35.5 years, P<0.0001) and more likely to have lower spinal segments affected than patients with type B PVAVSs (67.8% versus 13.9%, P=0.00006). After presentation, the deterioration rates related to gait and sphincter dysfunction were significantly higher in patients with type A than type B shunts (gait dysfunction: 71.8%/y versus 17.0%/y, P=0.0006; sphincter dysfunction: 63.7%/y versus 11.3%/y, P=0.0002). According to the angiogram at the end of the latest treatment, 79% of type A and 75% of type B PVAVSs were completely obliterated. If the lesions were partially obliterated, a significantly higher clinical deterioration rate was observed in patients with type A shunts than those with type B shunts (69.9%/y versus 3.2%/y, P=0.0253). CONCLUSIONS Type A PVAVSs feature rapid progressive neurological deficits; therefore, early clinical intervention is necessary. For complex lesions that cannot be completely obliterated, surgical disconnection of all refluxed radicular veins is suggested.
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Affiliation(s)
- Yueshan Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Jiaxing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Jiankun Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Lisong Bian
- Department of Neurosurgery, Beijing Haidian Hospital, China (L.B.)
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.).,International Neuroscience Institute, Beijing, China (Y.F., J.Y., J.X., C.H., G.L., M.Y., P.H., L.S., N.J., F.L., T.H., H.Z.)
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14
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Rothrock RJ, Haldeman C, Shah A, Lu VM, Lavi ES, Peterson EC, Levi AD. Challenges in Diagnosis and Management of Previously Embolized Spinal Dural Arteriovenous Fistulae. World Neurosurg 2021; 154:e710-e717. [PMID: 34358689 DOI: 10.1016/j.wneu.2021.07.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/24/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Given the growing prevalence of initial endovascular treatment for type 1 spinal dural arteriovenous fistulae (dAVF), there are an increasing number of patients presenting with progressive symptoms related to recurrent previously embolized spinal dAVF. This study's goal was to identify demographic, clinical, and radiographic variables among patients who have failed embolization of type I spinal dAVF. METHODS A retrospective review of 24 consecutive surgeries for type I spinal dAVF performed by the senior author (A.D.L.) identified 5 patients who underwent open surgery for failed embolization. These 5 cases were reviewed for location of fistula, time from embolization to recurrence, preoperative functional status, fistulous point encountered at surgery, and clinical outcome of the patient at 3-month follow-up. A representative example case is reviewed in detail. RESULTS The median age at time of recurrence was 63 years (range 51-73 years). The median timing of embolization to recurrence of neurologic symptoms was 5 months (range 1-54) and to surgery 7 months (range 2-60 months). The level of the spinal dAVF was most frequently at T12-L1 (n = 3). Spinal magnetic resonance arteriography led to localization of the spinal dAVF in 2 patients and spinal catheter angiogram in 3 cases. All patients had definitive radiographic cure of the dAVF at last clinical follow-up. CONCLUSIONS The increased use of endovascular treatment of spinal dAVF has led to the treatment of refractory cases with a greater degree of surgical complexity. Open surgical ligation continues to provide the most definitive treatment outcomes for this complex spinal vascular entity.
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Affiliation(s)
- Robert J Rothrock
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Clayton Haldeman
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ashish Shah
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Victor M Lu
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Efrat Saraf Lavi
- Department of Neuroradiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eric C Peterson
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan D Levi
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
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15
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Iampreechakul P, Liengudom A, Wangtanaphat K, Tirakotai W, Wattanasen Y, Lertbutsayanukul P, Siriwimonmas S. Spinal epidural arteriovenous fistula with intradural venous reflux: The possibility of acquired origin caused by spinal stenosis and/or disc herniation. Clin Neurol Neurosurg 2021; 207:106794. [PMID: 34245987 DOI: 10.1016/j.clineuro.2021.106794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/30/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal epidural arteriovenous fistulas (SEAVFs) are relative rare lesions. The pathogenesis of these fistulas remains unclear. Our aim is to review cases of SEAVFs at our institution. METHODS We reviewed a consecutive series of spinal vascular disease at our institution and collected all patients harboring SEAVFs. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, previous history of spinal surgery or trauma, treatment methods, and neurological outcome after treatment. All image studies, including plain radiography, spinal MRI, MRA, and angiography were analyzed. RESULTS We identified 9 cases of lumbosacral SEAVFs with intradural venous reflux treated at our institution from June 2010 to August 2020. Their median age was 67 years, range 52-83 years. Only one patient had a history of trauma. Interestingly, our observations found that all fistulas are associated with spinal stenosis and/or disc herniation. An additional literature search about SEAVFs coexisting with spinal stenosis and/or disc herniation was performed and found another 19 cases with median age 69 years, range 39-83 years. Only 2 patients had a history of previous spinal surgery. The level of shunted pouch in all 28 patients was correlated with the level of spinal canal stenosis and/or disc herniation. CONCLUSIONS Our study may provide an additional evidence supporting an acquired etiology of SEAVFs, which mainly manifest in late adulthood. It is possible that spinal stenosis and/or disc herniation may result in thrombosis or impairment of venous drainage, causing increased venous pressure, leading to fistulous formation.
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Affiliation(s)
| | - Anusak Liengudom
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand.
| | | | - Wuttipong Tirakotai
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand.
| | - Yodkhwan Wattanasen
- Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand.
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16
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Brinjikji W, Colombo E, Cloft HJ, Lanzino G. Clinical and Imaging Characteristics of Spinal Dural Arteriovenous Fistulas and Spinal Epidural Arteriovenous Fistulas. Neurosurgery 2021; 88:666-673. [PMID: 33428765 DOI: 10.1093/neuros/nyaa492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/09/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Spinal epidural arteriovenous fistulas (SEDAVFs) are an increasingly recognized form of spinal vascular malformation and are distinct from spinal dural arteriovenous fistulas (SDAVFs). Differentiating between these 2 entities is important as operative strategies often differ based on angioarchitecture. OBJECTIVE To compare demographic, clinical, anatomic, and imaging findings of SDAVFs and SEDAVFs. METHODS Consecutive patients diagnosed and/or treated for SDAVF or SEDAVF at our institution between January 2000 and November 2018 were included. Data were collected on demographics, clinical presentation, and imaging findings. All cross-sectional and angiographic imaging were reviewed. To compare continuous variables, t-test was used Chi-squared was used for categorical variables. RESULTS A total of 169 patients were included. In total 47 patients had SEDAVFs and 122 patients had SDVAFs. Clinical presentation and magnetic resonance imaging (MRI) imaging findings were similar between the 2 groups. SEDAVF patients were significantly more likely to have an epidural venous pouch on gadolinium bolus MR angiography (MRA) (0.0% vs 92.1%, P < .0001). SEDAVFs were more commonly located in the lumbar and sacral spine than SDAVFs (85.1% vs 34.4%, P < .0001). When in the lumbar spine, SEDAVFs unlike SDAVFs were more likely to involve the most caudal segments (L4 and L5, P = .02). CONCLUSION SEDAVF share clinical and radiological findings similar to SDAVFS, including high T2 cord signal, cord enhancement, and perimedullary flow voids on conventional MRI. However, they have a characteristic appearance on spinal MRA and DSA with a pouch of epidural contrast. SEDAVFs are more commonly located in the lumbosacral spine.
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Affiliation(s)
- Waleed Brinjikji
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Elisa Colombo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Harry J Cloft
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota; Department of Radiology, Mayo Clinic, Rochester, Minnesota
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17
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Intramedullary Hemorrhage Caused by Lumbosacral Epidural Arteriovenous Fistula with Dual Retrograde Perimedullary Venous Draining Routes: A Case Report and Review of the Literature. World Neurosurg 2020; 143:295-307. [DOI: 10.1016/j.wneu.2020.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 11/20/2022]
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18
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Iampreechakul P, Tirakotai W, Lertbutsayanukul P, Thammachantha S, Siriwimonmas S. Spontaneous Spinal Osseous Epidural Arteriovenous Fistula with Long Segments of Prominent Epidural Venous Drainage Causing Severe Compressive Thoracic Myelopathy Successfully Treated with Combined Endovascular and Surgical Treatments: A Case Report and Review of the Literature. Asian J Neurosurg 2020; 15:1041-1049. [PMID: 33708687 PMCID: PMC7869281 DOI: 10.4103/ajns.ajns_353_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 11/25/2022] Open
Abstract
The authors describe an extremely rare case of spinal osseous epidural arteriovenous fistulas (SOEAVFs) with unique characteristic features. A 25-year-old man presented with progressive weakness and paresthesia of the lower extremities for 1 month. Magnetic resonance imaging of the thoracic spine showed an extradural dilated vascular flow void structure extending from T4 to T8 levels with abnormal hyperintense T2 signal from T6 to T8 levels. Magnetic resonance angiography and spinal angiography revealed unique features of SOEAVF supplied by multiple small arterial feeders of intercostal arteries converging into a dilated round venous sac corresponding to a bony defect of T7 lamina and spinous process. The venous drainage directly drained into prominent epidural venous plexus extending from the level of T4 to T8 without intradural venous drainage, causing severe compressive myelopathy. Transarterial embolization was performed using N-butyl cyanoacrylate through the main feeder. Subsequently, he successfully underwent laminectomy and total excision of the fistula and large epidural draining venous plexus. Histopathology confirmed spinal vascular malformations with evidence of previous embolization. He gradually improved until being ability to walk independently 3 months later. Follow-up spinal angiography confirmed complete resection of SOEAVF. The patient has remained clinically asymptomatic 5 years after operation.
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Affiliation(s)
| | - Wuttipong Tirakotai
- Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
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19
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Posttraumatic Vertebral Arteriovenous Fistula: A Lifeline from Tetraplegia? World Neurosurg 2020; 142:413-419. [PMID: 32668335 DOI: 10.1016/j.wneu.2020.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Vertebral artery (VA) rupture is a rare condition that occurs about in 0.5% of cervical trauma. The management of our case was complicated by a spinal epidural hematoma (SEH) leading to worsening neurologic deficits. Only 1 similar case has been reported before in the literature. CASE DESCRIPTION We report the case of a 37-year-old victim of a serious car accident. Shortly after admission to the emergency department, she developed weakness in all 4 limbs and sensory deficit below T6 level. Cervical spine computed tomography scan revealed an SEH from C1 to T3. Computed tomography angiography scan showed rupture of the left VA at C3 level, with a posttraumatic vertebral arteriovenous fistula at the same level, draining in the epidural venous plexus and to the right jugular internal vein. Immediately after embolization of the left VA, we performed a cervical decompression from C2 to C7. Three months after surgery the patient had a full recovery. CONCLUSIONS No guidelines exist to treat this situation. We propose consequential steps to treat a posttraumatic cervical SEH with evidence of VA rupture.
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20
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Takai K, Endo T, Yasuhara T, Seki T, Watanabe K, Tanaka Y, Kurokawa R, Kanaya H, Honda F, Itabashi T, Ishikawa O, Murata H, Tanaka T, Nishimura Y, Eguchi K, Takami T, Watanabe Y, Nishida T, Hiramatsu M, Ohtonari T, Yamaguchi S, Mitsuhara T, Matsui S, Uchikado H, Hattori G, Horie N, Yamahata H, Taniguchi M. Microsurgical versus endovascular treatment of spinal epidural arteriovenous fistulas with intradural venous drainage: a multicenter study of 81 patients. J Neurosurg Spine 2020; 33:381-391. [PMID: 32330891 DOI: 10.3171/2020.2.spine191432] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal arteriovenous shunts are rare vascular lesions and are classified into 4 types (types I-IV). Due to rapid advances in neuroimaging, spinal epidural AVFs (edAVFs), which are similar to type I spinal dural AVFs (dAVFs), have recently been increasingly reported. These 2 entities have several important differences that influence the treatment strategy selected. The purposes of the present study were to compare angiographic and clinical differences between edAVFs and dAVFs and to provide treatment strategies for edAVFs based on a multicenter cohort. METHODS A total of 280 consecutive patients with thoracic and lumbosacral spinal dural arteriovenous fistulas (dAVFs) and edAVFs with intradural venous drainage were collected from 19 centers. After angiographic and clinical comparisons, the treatment failure rate by procedure, risk factors for treatment failure, and neurological outcomes were statistically analyzed in edAVF cases. RESULTS Final diagnoses after an angiographic review included 199 dAVFs and 81 edAVFs. At individual centers, 29 patients (36%) with edAVFs were misdiagnosed with dAVFs. Spinal edAVFs were commonly fed by multiple feeding arteries (54%) shunted into a single or multiple intradural vein(s) (91% and 9%) through a dilated epidural venous plexus. Preoperative modified Rankin Scale (mRS) and Aminoff-Logue gait and micturition grades were worse in patients with edAVFs than in those with dAVFs. Among the microsurgical (n = 42), endovascular (n = 36), and combined (n = 3) treatment groups of edAVFs, the treatment failure rate was significantly higher in the index endovascular treatment group (7.5%, 31%, and 0%, respectively). Endovascular treatment was found to be associated with significantly higher odds of initial treatment failure (OR 5.72, 95% CI 1.45-22.6). In edAVFs, the independent risk factor for treatment failure after microsurgery was the number of intradural draining veins (OR 17.9, 95% CI 1.56-207), while that for treatment failure after the endovascular treatment was the number of feeders (OR 4.11, 95% CI 1.23-13.8). Postoperatively, mRS score and Aminoff-Logue gait and micturition grades significantly improved in edAVFs with a median follow-up of 31 months. CONCLUSIONS Spinal epidural AVFs with intradural venous drainage are a distinct entity and may be classified as type V spinal vascular malformations. Based on the largest multicenter cohort, this study showed that primary microsurgery was superior to endovascular treatment for initial treatment success in patients with spinal edAVFs.
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Affiliation(s)
- Keisuke Takai
- 8Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo
| | - Toshiki Endo
- 2Department of Neurosurgery, Kohnan Hospital, Sendai
| | - Takao Yasuhara
- 13Department of Neurosurgery, Okayama University Graduate School of Medicine, Okayama
| | - Toshitaka Seki
- 1Department of Neurosurgery, Hokkaido University Hospital, Sapporo
| | - Kei Watanabe
- 3Department of Orthopaedic Surgery, Niigata University Medical and Dental Hospital, Niigata
| | - Yuki Tanaka
- 3Department of Orthopaedic Surgery, Niigata University Medical and Dental Hospital, Niigata
| | - Ryu Kurokawa
- 4Department of Neurosurgery, Dokkyo Medical University Hospital, Tochigi
| | - Hideaki Kanaya
- 4Department of Neurosurgery, Dokkyo Medical University Hospital, Tochigi
| | - Fumiaki Honda
- 5Department of Neurosurgery, Gunma University Hospital, Gunma
| | - Takashi Itabashi
- 6Department of Orthopaedic Surgery, Japanese Red Cross Narita Hospital, Chiba
| | - Osamu Ishikawa
- 7Department of Neurosurgery, The University of Tokyo Hospital, Tokyo
| | - Hidetoshi Murata
- 9Department of Neurosurgery, Yokohama City University Hospital, Yokohama
| | - Takahiro Tanaka
- 9Department of Neurosurgery, Yokohama City University Hospital, Yokohama
| | - Yusuke Nishimura
- 10Department of Neurosurgery, Nagoya University Hospital, Nagoya
| | - Kaoru Eguchi
- 10Department of Neurosurgery, Nagoya University Hospital, Nagoya
| | - Toshihiro Takami
- 11Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka
| | - Yusuke Watanabe
- 11Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka
| | - Takeo Nishida
- 12Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka
| | - Masafumi Hiramatsu
- 13Department of Neurosurgery, Okayama University Graduate School of Medicine, Okayama
| | - Tatsuya Ohtonari
- 14Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, Hiroshima
| | - Satoshi Yamaguchi
- 15Department of Neurosurgery, Hiroshima University Hospital, Hiroshima
| | | | - Seishi Matsui
- 16Department of Neurosurgery, Ehime University Hospital, Ehime
| | - Hisaaki Uchikado
- 17Department of Neurosurgery, Kurume University Hospital, Fukuoka
| | - Gohsuke Hattori
- 17Department of Neurosurgery, Kurume University Hospital, Fukuoka
| | - Nobutaka Horie
- 18Department of Neurosurgery, Nagasaki University Hospital, Nagasaki; and
| | - Hitoshi Yamahata
- 19Department of Neurosurgery, Kagoshima University Hospital, Kagoshima, Japan
| | - Makoto Taniguchi
- 8Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo
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