Spinal dural arterio-venous fistula with multiple points of shunt

Summary A 45-year-old man presented with a history of dysaesthesiae, sensory impairment of the legs and sphincter disturbances. Selective angiography showed a mid-thoracic dural arterio-venous fistula with five shunt points. The venous plexuses were demonstrated by injections at T5 on the right side and T6 on the left, but the venous pattern on the two sides did not overlap. Angiography did not unquestionably point to any single location of a fistula, as would normally be expected. During surgery five dorsal locations of shunt were identified. We have not found any publication describing a spinal dural arterio-venous fistula with multiple venous drainage channels at the same level.     

Long-Term Prognosis of Haemangioblastoma of the CNS: Impact of von Hippel-Lindau Disease

The aim was to assess the frequency of von Hippel-Lindau disease (VHL) and the long-term prognosis of VHL and non-VHL patients among 110 consecutive patients with haemangioblastoma (HB) of the CNS treated between 1953 and 1993 at one neurosurgical unit. To reveal VHL manifestations we performed a detailed clinical and radiological examination (neuraxis and abdomen) (61/110), VHL-gene mutation analysis (40/110), and collection of all available clinical, imaging, operative and autopsy data from the hospitals involved. All patients were followed-up with a median of 14 years (excluding 14 operative deaths), and no patient was lost to follow-up. Altogether 49 patients died during the follow-up. In the 14 VHL patients (13%), HB(s) of the CNS were detected at a median age of 33 years, retinal HB(s) at 39 years, and renal cell carcinoma (RCC) at 43 years. The frequency of VHL in patients operated on for HB(s) was 29% before the age of 25 years, 19% between 25 and 45 years, and only 2% after 45 years. HB patients not meeting the VHL criteria had internal organ cysts in 14%. One non-VHL patient (4%) had two adjacent HBs in the same cyst wall. The growth rates of non-VHL and VHL-related HBs were similar as indicated by the median time to recurrence and the proliferation indices (MIB-1). Recurrence of the HB in patients whose primary operation was considered radical developed in four of the 10 VHL patients at a median of 19 years, and in nine of the 74 non-VHL patients at a median of 11 years. The median length of life of all VHL and non-VHL patients was 46 and 63 years, respectively. In VHL, RCC and HBs were equal causes of death.     

Haemangioblastoma of a cervical sensory nerve root in Von Hippel-Lindau syndrome

Spinal haemangioblastomas are rare, accounting for only about 7% of all central nervous system cases. The case of a 40-year-old woman with a haemangioblastoma arising solely from a cervical sensory nerve root is presented. At operation via a cervical laminectomy, it was possible to resect the tumour en masse with the sensory ramus, by extending the laminectomy through the exit foramen for C6. Haemangioblastomas are commonly intramedullary, and have only been reported in this location on one previous occasion. The patient has Von Hippel-Lindau syndrome and a history of multiple solid tumours. The possible role of the Von Hippel-Lindau tumour suppressor gene in the pathogenesis of these neoplasms is discussed. Received: 15 January 2000/Revised: 2 June 2000/Accepted: 14 June 2000     

Arteriovenous shunts between dural branches of the carotid artery and the cavernous sinus

Three cases with dural arteriovenous shunts of the cavernous sinus are reported. The clinical signs usually were mild and included frontal headache, dilated conjunctival veins, exophthalmos, bruit, and oculomotor nerve palsy. Arterial contributions to the fistulae arose from meningeal branches of the internal and external carotid arteries. The precise diagnosis was made by selective angiography supplemented by subtraction and magnification techniques. The distal occlusion of the feeding arteries close to the shunt offers advantages when compared with conventional vessel ligation because of a more effective exclusion of vascular abnormalities from the circulation.     

人工脑膜在颈胸椎手术硬膜损伤中的应用

[目的]探讨人工脑膜在颈胸椎手术硬膜损伤中的应用.[方法]2004年5月～2009年12月共行颈胸椎手术557例,共发生1l例手术中硬膜损伤.对硬膜裂口<1cm的7例患者采用直接缝合修补硬膜;对硬膜缺损的4例患者以及直接缝合硬膜后出现皮肤、皮下脑脊液漏的3例患者采用人工脑膜修补硬膜,术后均予头高脚低位和伤口加压包扎治疗.统计不同手术节段范围和手术入路时硬膜损伤的发生率.[结果]4例硬膜缺损患者用人工脑膜修补硬膜,手术后未发生脑脊液漏.7例直接缝合硬膜的患者中,4例治愈,3例手术后出现伤口持续性脑脊液漏,经人工脑膜修补硬膜,封闭椎管,获得痊愈.多节段颈胸椎手术中硬膜损伤的发生率高于单节段患者.[结论]人工脑膜修补硬膜,可有效预防和治疗颈、胸椎手术中硬膜破损所致术后脑脊液漏.     

Multiple spinal dural arteriovenous fistulas

Summary Multiple spinal dural arteriovenous fistulas (DAVFs) have been rarely reported and only two such cases are found in the literature. A 71-year-old man complained of muscle weakness and hypesthesia in both legs and angiographically diagnosed as thoracic DAVF. The fistula was surgically treated, however, the symptoms recurred 14 months after the first treatment. Angiography revealed a new fistula in the lumbar region and this was also treated surgically. In the previously reported cases of multiple spinal DAVFs, the second fistulas were also diagnosed after the initial treatment. Symptomatic patients after the initial treatment of DAVF should be re-examined angiographically.     

Fibrotic-haemorrhagic reaction to synthetic dural substitute

Summary A case is presented in which a patient developed a complication related to the use of Silastic dural substitute. Ten years after the initial surgery, a fibrotic-haemorrhagic reaction around the graft material was found, mimicking a recurrent meningioma clinically and radiologically. A review of the literature and suggested mechanisms of these complications are reported.     

Observations on deliberate dural puncture with a Tuohy needle: pressure measurements

Pressure recordings were made during passage of a Tuohy needle from the interspinous ligament to the subarachnoid space for lumbar drain insertion. Epidural space pressures were always positive. Negative pressures were seen only at the moment of entry into the subarachnoid space. These were artefactual and were caused by tenting of the dura by the blunt Tuohy needle. Use of a closed measurement system such as this facilitates the development of large transdural pressure gradients because of the inability of the epidural space pressure to equilibrate with atmospheric pressure. This may contribute to ease of dural puncture.     

Observations on deliberate dural puncture with a Tuohy needle: depth measurements

Observations were made during the use of a Tuohy needle to perform deliberate dural puncture for the insertion of lumbar drains to improve operating conditions for intracranial aneurysm surgery. The most striking finding was the distance from identification of the epidural space to penetration of the dura. We postulate that this was because of tenting of the dura by the blunt Tuohy needle. This was facilitated by the absence of a negative epidural space pressure because an open system was used, which allowed time for pressure equilibration. This minimised the reactive forces across the dura. Aspiration and rotation of the Tuohy needle revealed dural puncture in some cases.     

Acute extradural hematoma associated with silastic dural substitute: Case report

The author reports the occurrence of an acute extradural hematoma associated with a silastic dural substitute, originally implanted 13 years previously. A recurrent malignant meningioma also arose at the site of the previous surgery.     

Transvenous embolisation of dural carotid-cavernous fistulas by multiple venous routes: a series of 27 cases

Summary.  Background: Transvenous embolisation is an effective option in the treatment of dural carotid-cavernous fistulas (DCCFs). This can be achieved via a number of venous routes.  Method: From 1997 to 2001, 27 patients with DCCFs (15 unilateral and 12 bilateral) were treated by transvenous embolisation with Guglielmi detachable coils and fibered platinum coils. The transvenous embolisation routes included inferior petrosal sinus (IPS) alone (18 patients), IPS and inter-cavernous sinus (6 patients), IPS and clival plexus (1 patient), superior ophthalmic vein (SOV) via facial vein (1 patient) and SOV via superficial temporal vein (1 patient). One patient required further transarterial embolisation with polyvinyl alcohol particles.  Findings: The follow-up period ranged from 4 to 57 months (average 26 months). Two patients had transient ophthalmoplegia and 2 patients had symptomatic recurrence of the DCCF during the follow-up. There was no permanent procedure-related morbidity. Clinical cure was achieved in 26 patients (96%) and complete angiographic obliteration was documented in 24 patients (89%).  Interpretation: DCCFs can be successfully treated by transvenous embolisation via different venous routes. Published online January 14, 2003 Acknowledgments  We thank Lap-Chung Tang for the hand drawings and Dr. Kwok-Hung Lai for computer graphics. We also thank Kwun-Lin Man, Marina Lee and Emily Tin for assistance in the secretarial work.  Correspondence: K.-M. Cheng, Department of Neurosurgery, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong, China.     

Pathogenetical consideration of spontaneous dural arteriovenous fistulas (DAVFs)

Summary Sinus thrombosis has been regarded as an aetiological factor in DAVFs. However, this claim has been disputed in the literature, because it is not possible to prove that DAVFs arise as a result of sinus thrombosis in all cases, and there is evidence that venous thrombosis can be acquired from a DAVF. The purpose of this study is to examine the hypothesis that the different angiomorphologies of DAVFs depend on the location of their venous outflow, and that a territorial classification of spontaneous DAVFs can be created which is based on their acquired development as a consequence of the breakdown of autoregulation of dural microvascularisation after venous thrombosis.The clinical and radiographic findings of 96 patients with DAVFs were reviewed. The angiomorphology of these lesions was examined using extensive prospective and retrospective angiographic studies, especially with regard to their venous characteristics. The associated phlebothrombosis of the venous outflow was determined in all cases by angiography, and in 8 cases by CT or MRI. We also applied the Venturi effect, a well-confirmed engineering principle, to propose a new hypothesis concerning the development of acquired DAVFs: namely, that there is an acceleration of the shunt volume of the physiological dural AVshunts after a breakdown of their autoregulation occurs. This acceleration seems to be proportional to the flow volume of the venous outflow.The imaging examination showed venous thrombosis in 51 cases. In 98% (44) of the non-thrombotic cases, predisposing histories for phlebothrombosis were documented — for example, hypercoagulable states (venous embolism, phlebothrombosis of the leg, cardiac disease), diabetes mellitus, chronic otitis media, or various low-grade infections. In addition, in 78% of the non-thrombotic cases (excluding the DAVFs of the venous plexus at the base of the skull) there were also angiographically documented deformations of the sinus wall, including hypoplasia of the sigmoid or transverse sinus (20 cases), segmental narrowing of the sinus (8 cases), septation of the sinus lumen (2 cases), and cavernous nodules projecting into the lumen of the transverse (6 cases), sigmoid (4 cases), or sagittal (3 cases) sinuses. The clinical presentation suggested that DAVFs probably develop after a breakdown of the autoregulation of the physiological AV shunts resulting from a venous thrombosis, when there are suitable arteriovenous pressure gradients in the venous recipient. This development would depend on the haemodynamic action of the Venturi effect. The causal phlebothrombosis prior to DAVF may arise in the region of the sinus lumen, the intradural segments of afferent veins, the emissary veins, the venous plexus at the base of the skull, or the residual lumen of an aberrant dural sinus (falciform sinus). In terms of their location and pathogenesis, DAVFs are subdivided into five groups: Type 1 — DAVFs of the dural sinuses (39); Type 2 — DAVFs of the cavernous sinus (29); Type 3 — DAVFs of Galen's system (10); Type 4 — DAVFs of the venous plexus at the base of the skull (9); Type 5 — DAVFs of the cortical veins situated near the dural sinuses (9). The documentation of a sinus thrombosis depends on the location of the DAVM: in 72% of the cases with type 1 DAVFs there was a thrombosis at the time of the investigation, but no thrombosis could be proved in cases with type 4 DAVFs.The reason for the impossibility of identifying a previous causal probably venous sinus thrombosis in cases with DAVFs appears to be either the generally subclinical symptoms of these lesions or their bland clinical course. Moreover, even if a thrombosis precedes the development of type 4 and type 5 DAVFs, its clinical and imaging documentation is not feasible in practice. The morphological development of an actual DAVF begins with the activation of the Venturi effect. A pronounced development of pathological AV shunts simultaneous with a general rise in shunt volume takes place at the level of the large basal dural sinuses (type 1) or of the straight sinus (type 3). On the other hand, a delayed development of pathological AV shunts with a mainly low shunt volume occurs in a venous channel with a low arteriovenous pressure gradient — as, for example, in the region of the cortical veins situated near the dural sinuses (type 5), the venous plexuses at the base of the skull (type 4), the tentorial sinuses (type 3 or type 5), some cavernous sinuses (type 2), or in cases with morphological stenosis or hypoplasia of the sinus.     

Accidental dural puncture during epidural blood patch: a narrative review

Whilst performing an epidural blood patch (EBP) to treat post dural-puncture headache following accidental or intentional dural puncture, the risk of a subsequent accidental dural puncture (ADP) is commonly quoted as 1%. However, a recent review reported only three documented cases. It seems likely that this complication is more common than is acknowledged, yet there is a paucity of literature and an absence of any guidance as to how to proceed in practice. This review addresses three unanswered questions regarding ADP during EBP: what is the incidence; what are the immediate clinical consequences; and what is the optimal clinical management?The incidence may reasonably be estimated to be 0.5–1%. Even on large units, this complication will not be experienced by every consultant anaesthetist during their career. It is likely to occur 20–30 times per year in the United Kingdom, and in greater numbers in those countries with higher epidural rates. Immediately re-attempting an EBP at a different level may be a reasonable management approach which has high efficacy, and is without clear evidence of significant harm. However, the limited evidence means that the risks are poorly characterised, and more data may lead to alternative conclusions.There is uncertainty amongst obstetric anaesthetists about how to manage ADP during EBP. More data and pragmatic guidance, which evolves with further evidence, will ensure optimal care for patients suffering this compound iatrogenic complication.     

The role of angiogenic factor bFGF in the development of dural AVFs

SummaryPurpose Dural arteriovenous fistulas (dAVFs) are known to be acquired disorders. Angiogenic stimulants, such as basic fibroblast growth factor (bFGF), may be involved in the evolution of this disorder. We examined the appearance and localization of bFGF, in human dAVF sinuses, versus a control using immunohistochemical techniques, to evaluate these qualitative differences.Patients and methods Four human dural sinuses from dAVF patients, and one control dural sinus were removed at surgery or autopsy and used for this study. Immunohistochemistry for bFGF was performed in all five specimens to identify its appearance and localization. Immunohistochemistry for alpha smooth muscle actin, factor VIII related antigen, and macrophage (CD-68) were done in all tissues to identify the bFGF positive cell types.Results In the control dural sinus, there was negative staining by bFGF immunohistochemistry. However, in all four sinuses of the dAVF patients, smooth muscle cells, endothelial cells, and meningeal cells were stained positively in various degrees by bFGF immunohistochemistry.Conclusion bFGF may be significant in the development of dAVFs, judging from its strong immunoreactivity in the sinuses of dAVF patients.     

Relief of postural post dural puncture headache by an epidural blood patch 12 months after dural puncture

A 20-year-old previously healthy male presented at the pain clinic with chronic headache of about one year duration. Clinical examination revealed no pathological manifestations. During the consultation the patient was drinking Coca-Cola. On direct questioning he told that drinking Coca-Cola gave partial relief from the headache, and that the headache started after he had received two spinal anaesthetics for treatment of a lower leg fracture. Postural post dural puncture headache was now suspected and an epidural blood patch performed. Despite an interval of nearly 12 months since the dural punctures, a single epidural blood patch completely relieved the headache. This case history demonstrates that an epidural blood patch should be tried if a chronic post dural puncture headache is suspected.     

Treatment and outcome of spinal dural arteriovenous fistulas

Spinal dural arteriovenous fistula (dAVFs) are rare and often misdiagnosed entities. The choice between surgical treatment and embolization remains a matter of debate. We report on the cases of 18 patients (16 men, 2 women) with dAVF, who were treated surgically over an 11-year period. Patient age ranged from 32 to 84 years (mean 60 years). Six patients underwent embolization preoperatively. In three cases, angiography examinations failed to show feeding arteries on first examination at neuroradiological centers. Feeding arteries were at a different level than the fistula point in seven patients, two of them presenting with new anastomoses after embolization. Location of the fistula was midthoracic to lumbar. Seven patients were variously misdiagnosed with tumor, polyneuropathy, Guillain-Barré syndrome, syringomyelia, and knee disease. Clinical history was characterized by slowly progressive and fluctuating deterioration. Initial symptoms were mainly sensory loss and motor weakness, lasting for between 4 and 45 months before diagnosis (mean 15 months). Recurrent fistula after operation was found in one patient. In another patient, control angiography revealed a fistula at another level, and in a third, a fistula on the contralateral side. All three patients underwent reoperation. Temporary clinical deterioration was found in four patients, seven remained unchanged, and seven improved postoperatively. An attempt at embolization should be made following diagnostic angiography. Otherwise, surgery is our recommended treatment for spinal dural fistulas, as it has a lower failure rate. Because of the progressive natural course with severe deficits, we favor an early definitive treatment.     

The traumatic dural sinus injury — a clinical study

Summary In a period of 13 years 978 cases of severe head injuries were operated on in our clinic. An analysis of the medical reports includes injuries of the superficial dural sinus (39 cases=4%): among these injuries of the anterior and central part of the superior sagittal sinus (66 per cent), injuries of the transverse sinus (18 per cent), injuries of the posterior part of the superior sagittal sinus (8 per cent), and combined injuries of different dural sinuses (8 per cent).Clinical data, i.e. the causes of accident, radiological examination results, intracranial lesions, operation technqiues and outcome are analysed and discussed. The analysis of cases with dural sinus injuries shows a high mortality rate (total mortality rate: 16 patients=41%; intra-operative mortality rate: 8 patients=20%).     

经肺动脉与支气管动脉血管造影的CTA观察原发肺癌的血供

目的用支气管动脉(BA)和肺动脉(PA)造影CTA观察肺癌血供情况。方法前瞻性观察6例支气管肺癌患者,分别行体循环动脉和肺动脉数字减影血管造影(DSA)后,留置BA导管与PA导管行CTBA与CTPA,观察BA与PA对肺癌的血供。结果CTPA上,无体动脉与左心强化的图像上肿瘤未见强化,有体动脉或左心强化的图像上见肿瘤边缘强化,CT强化值为10.0~45.6 Hu。CTBA上肿瘤部分明显强化,CT强化值为150.3~320.7 Hu,可见杂乱无章的肿瘤血管影,3例见纵隔淋巴结强化。结论本组病例观察表明原发性肺癌由BA为主的多发体循环动脉供血,未发现PA参与供血。     

Factors that affect the surgical outcomes of spinal dural arteriovenous fistulas

BACKGROUND: Authors disclose the factors that affect the surgical outcome of the spinal dural AVFs from the retrospective analysis of 13 cases. METHODS: Thirteen patients with spinal dural AVF underwent microsurgical treatments between 1990 and 2004 at the Department of Neurosurgery, Aso Iizuka Hospital. The mean age was 62 years, and the median time to diagnosis was 38 months (range, 4-120 months). There were 12 men and 1 woman. The clinical features were characterized by spastic paraparesis in all 13 patients and micturition problem in 11 patients. All 13 patients showed the longitudinal extension of the high T2 intramedullary signals in magnetic resonance (MR) image. The microsurgical obliterations of the spinal dural AVFs were performed for all 13 patients because the endovascular treatments were difficult or failed to obliterate the lesions. RESULTS: The durations of the symptoms were not directly correlated to the preoperative neurological conditions and the postoperative outcomes. The patient's age and the preoperative severity of myelopathy affected the postoperative outcomes. The mode of the longitudinal extension of the high T2 intramedullary signals in MR image, rostral or caudal, did not show the statistical significance to the outcome. The poor outcomes were observed in elderly patients and patients with preoperative modified Rankin Scale 4 and 5. A case with multiple spinal dural AVFs is also presented. CONCLUSION: The spinal AVFs are treatable lesions through microsurgery or embolization. The likelihood of favorable outcome was affected by the severity of deficits and the patient's age.