Imaging in spinal vascular disease

Spinal vascular diseases are rare and constitute only 1% to 2% of all vascular neurologic pathologies. In this article, the following vascular pathologies of the spine are described: spinal arterial infarcts, spinal cavernomas, and arteriovenous malformations (including perimedullary fistulae and glomerular arterivenous malformations), and spinal dural arteriovenous fistulae. This article gives an overview about their imaging features on MRI, MR angiography, and digital subtraction angiography. Clinical differential diagnoses, the neurologic symptomatology, and the potential therapeutic approaches of these diseases, which might vary depending on the underlying pathologic condition, are given.     

Intracranial dural arteriovenous fistula with spinal venous drainage]

Two cases of intracranial dural arteriovenous fistulae draining into the medullary veins are reported. One patient was a 68-year old man who experienced brief and repeated episodes of paraplegia, followed by a permanent spinal cord syndrome. The other patient was a 74-year-old woman who rapidly developed a syndrome of the medulla and spinal cord. In both cases spinal cord angiography failed to show vascular malformations, but myelography revealed venous imprints and magnetic resonance imaging of the cervical spinal cord disclosed a pre-medullary signal. Cerebral angiography showed an intracranial arteriovenous fistula fed by the external carotid artery and draining into the veins of the posterior fossa and the spinal venous network. Complete occlusion of the fistula was achieved by embolization with microparticles. Intracranial dural arteriovenous fistulae draining into the medullary veins are rare: to our knowledge, only 4 cases have been reported. Such lesions must be considered whenever a spinal cord syndrome has no detectable cause.     

Vascular myelopathies-vascular malformations of the spinal cord: presentation and endovascular surgical management

Spinal cord vascular malformations are often a cause of spinal myelopathy. Endovascular surgical approaches to spinal cord vascular malformations have become an important adjunct and often the primary treatment of these disorders. Spinal cord vascular malformations may be divided into several categories based on their anatomy and location. They may present with a wide range of symptoms far removed from the vascular pathology. Early recognition and treatment can effect a better outcome and often reverse presenting neurologic deficits. Emerging magnetic resonance imaging techniques allow visualization of flow voids, some vascular anatomy, and intramedullary pathology and are a good screening modality. However, selective diagnostic spinal angiography remains the study of choice to diagnose and elaborate on the anatomy and potential treatment protocols. Rapidly evolving endovascular techniques and technology are revolutionizing the treatment of vascular pathology in the central nervous system, either as an adjunct to traditional neurosurgical techniques or as definitive therapy. We review the diagnosis and treatment options for spinal cord vascular malformations.     

脊髓硬脊膜动静脉瘘的临床特点(附2例报道和222例文献分析)

目的探讨脊髓硬脊膜动静脉瘘的发病机制和临床特征,以增进对该病的认识,减少误诊误治。方法报道2例临床病例,附1例手术和病理所见。结合文献中222例报道,进行临床分析。结果脊髓硬脊膜动静脉瘘是脊髓动静脉性血管病变的一种类型,临床表现为进行性、上行性的双下肢运动、感觉、大小便功能障碍,由于该病早期的症状和体征无特异性,易造成误诊,脊髓MRI和脊髓血管造影有特征性表现。结论对急性、亚急性病程的脊髓病变患者的MRI图像认真分析,并进行选择性脊髓血管造影检查,有利于早期确诊本病。早期诊断、早期治疗可以较好地改善临床症状。     

Spinal cord ischemia

Traditional data and recent advances in the field of spinal cord ischemia are reviewed, with special attention to clinical and radiological features, as well as underlying etiology, outcome, and pathophysiology. Acute spinal cord ischemia includes arterial and venous infarction and global ischemia resulting from cardiac arrest or severe hypotension. MRI has become the technique of choice for the imaging diagnosis of spinal cord infarction. Correlation of clinical and MRI data has allowed diagnosis of clinical syndromes due to small infarcts in the central or peripheral arterial territory of the spinal cord. Diffusion-weighted MR imaging may increase the sensitivity and specificity for diagnosis of acute spinal cord infarction. Diagnosis of venous spinal cord infarction remains difficult. As for global ischemia, neuropathological studies demonstrated a great sensitivity of spinal cord to ischemia, with selective vulnerability of lumbosacral neurons. Chronic spinal cord ischemia results in a syndrome of progressive myelopathy. The cause is usually an arteriovenous malformation. Most often, diagnosis may be suspected on MRI, leading to diagnostic, and eventually therapeutic, spinal angiography.     

Vertebro-epidural lumbosacral vascular malformations. An unusual cause of lumbo-sciatic pain

Sciatica is most commonly caused by nerve root compression secondary to herniated disk. Rarely, it can be due to a lumbosacral vascular malformation. We present five cases with such a malformation, presenting as a chronic lumboradiculagia. The patients were explored with computed tomography, MRI and selective spinal angiography. Polymorphic anatomic and hemodynamic aspect of these cases are reported: 1. One vertebral hemangioma with epidural extension; 2. Three purely epidural malformations: a) one epidural cavernous hemangioma, b) one epidural arteriovenous malformation, c) one epidural varix; 3. One paravertebral arteriovenous fistula with epidural venous drainage. Diagnosis of these rare malformations may be difficult. A multiplanar cross-sectional magnetic resonance and computed tomography scan with contrast enhancement can show characteristic abnormalities and may assist in recognition these malformations. Selective spinal angiography confirms the diagnosis, allows to classify the malformation and is required to evaluate endovascular therapeutic possibilities.     

Magnetic Resonance Angiography in Glomus Arteriovenous Malformation of the Cervical Spine

Conventional magnetic resonance imaging (MRI) and spine magnetic resonance angiography (MRA) demonstrated a glomus-type intradural arteriovenous malformation of the upper cervical region of the spine in a 24-year-old woman. Gadolinium-enhanced, three-dimensional, phase-contrast angiography displayed the nidus and feeders of the arteriovenous malformation. The clinical features of the two most common types of spinal arteriovenous malformations (dural arteriovenous fistula and glomus intradural arteriovenous malformation) are reviewed. Conventional MRI and spine MRA may obviate the need for performing total spinal myelography in patients suspected of having spinal arteriovenous malformations.     

硬脊膜动静脉瘘的手术治疗

目的探讨硬脊膜动静脉瘘的诊断及总结手术治疗的经验。方法回顾性分析13例经脊髓血管造影确诊的硬脊膜动静脉瘘患者的临床资料，均行手术夹闭瘘口，其中经全椎板切除入路9例，经半椎板切除入路4例。结果瘘口位于上胸段2例，中胸段3例，下胸段6例，腰段2例。全部病例手术后行脊髓血管造影复查，均未见异常瘘口及迂曲引流静脉。随访2—36个月，13例中症状基本消失、痊愈5例，症状改善、好转7例，无变化1例。结论脊髓血管造影可以准确定位瘘口位置，是诊断硬脊膜动静瘘的金标准。手术夹闭瘘口方法简单，夹闭瘘口确切可靠，效果肯定，可作为硬脊膜动静脉瘘的首选治疗方法。     

Interventional angiography in neuropediatrics

Since the introduction of non-invasive imaging techniques (CT, US, MRI), superselective cerebrospinal angiography has been playing a major role as a diagnostic tool as well as a therapeutic procedure prior to surgery or as an alternative. Surgical neuroangiography is now also a well-established therapeutic technique in neuropediatrics. Lesions fed by the external carotid artery and spinal cord lesions are the main indications. The first group consists of maxillofacial vascular malformations, nasopharyngeal angiofibromas, and vascularized tumors of the facioorbital area (hemangiopericytoma, angiosarcoma ...). Spinal lesions for which embolization can be considered are benign tumors of the vertebral column (vertebral hemangioma, aneurysmal bone cyst ...) and vascular malformations intrinsic to the spinal cord. Particles (Ivalon, dura) are the safest embolization materials and have a wide range of possible applications; glues such as IBC have defined but limited indications. Digital subtraction angiography is crucial during the procedure and in determining the overall doses of contrast medium to be administered. Furthermore, decisions can be made more rapidly and precisely, with a definite improvement in the therapeutic results.     

脑脊髓血管造影4D成像技术及其在脑脊髓血管病中的应用

目的 探讨脑脊髓血管造影4D成像技术及其在脑脊髓血管病诊治中的应用价值。方法 回顾性分析2018年1月至2022年1月收治的57例脑脊髓血管病的临床资料。使用双平板DSA机行2D-DSA、3D-DSA、4D-DSA数据采集,再将原始成像数据传输到后处理工作站,利用成像软件重建动态全循环立体影像。结果 57例中,脑动静脉畸形37例,硬脑膜动静脉瘘10例,硬脊膜动静脉瘘5例,脊髓髓周动静脉瘘2例,脊髓动静脉畸形2例,硬脊膜外动静脉瘘1例。4D-DSA均做出正确诊断,指导显微手术或血管内治疗,取得满意效果。结论 4D-DSA对影像进行动态分析,提供更精准的影像,丰富了脑脊髓血管病诊断金标准（DSA含金量）,对脑脊髓血管病的精准治疗有指导价值。     

吲哚菁绿术中荧光造影在脊髓硬脊膜动静脉瘘手术中的应用

目的 探引哚菁绿术中荧光造影术在脊髓硬脊膜动静脉瘘手术中的作用.方法 9例脊髓硬脊膜动静咏瘘患者,均经脊髓DSA确诊,行后正中全椎板切开,术中吲哚菁绿荧光造影明确供血动脉、引流静脉及瘘口,夹闭瘘口并选择性切除静脉血管畸形.结果 畸形血管位于颈段1例、胸段4例、胸腰段2例、腰段1例、胸腰骶段1例;介入栓塞不充分后转手术1例,介入栓塞微导管难以到位转手术8例;术后MRI显示髓周异常迂曲畸形血管消失,脊髓缺血水肿好转.术后症状消失2例,改善6例,无变化1例.结论 吲哚菁绿术中荧光造影能够明确供血动脉、引流静脉及瘘口情况,有效地提高了脊髓硬脊膜动静脉瘘手术的疗效.

Abstract：

Objective To evaluate the clinical significance of intraoperative indocyanine green (ICG)videoangiography in surgical management of spinal dural ateriovenots fistulae (dAVFs).Method In this retrospective analysis we examined nine cases of dAVFs, diagnosed by complete spinal angiography,in which laminoplasty were performed through posterior approach.An operating microscope - integrated light source containing infrared excitation light illuminated the operating field and was used to visualize an intravenous bolus of ICG.The locations of fistulae, feeding arteries and draininig veins were identified and compared before and after surgical obhteration by intraoperative ICG videoangiography.Results In the nine cases the dAVFs involved one cervical cord, four thoracic cord,two thoracic lumbar cord, one lumbar cord and one thoracic and lumbosacral cord.One of them used to take an unsuccessful endovascular embolization, while the rest of them were given the operation right after diagnosed by the spinal angiography.Microscope-based ICG videoangiography identified the fistulous point(s),feeding arteries and draining veins in all nine cases,as confirmed by postoperative MRI which showed complete obliteration of the dAVFs with improved spinal blood supply and reduced spinal cord edema.After the operation the clini cal symptoms were nearly disappered in two cases, improved in six cases, and present no obvious changes in one case.Conclusions Intraoerative ICG videoangiography provides real -time information about the precise location of spinal dAVFs,the feeding arteries and the draining veins, as well as additional feeding aiteries unrevealed by the preoperative spinal angiography and residue pathologic blood vessels during the operation, which efficiently improves the surgical outcomes and prognosis.     

Surgical treatment of spinal vascular malformations performed using intraoperative indocyanine green videoangiography

This study aims to evaluate the benefits of intraoperative indocyanine green (ICG) videoangiography and associated surgical outcomes of patients with spinal vascular malformations. ICG videoangiography was used during 24 surgical interventions to treat spinal vascular malformations at the Beijing Tiantan Hospital from August 2009 to May 2011. The vascular malformations were removed or the fistulae were occluded with the assistance of ICG videoangiography. The completeness of fistula clipping or nidus extirpation and each patient’s neurological status were evaluated. Among these 24 patients, there were seven with spinal dural arteriovenous fistulae, five glomus arteriovenous malformations, one juvenile arteriovenous malformation, nine perimedullary arteriovenous fistulae, and two perimedullary arteriovenous fistulae in combination with perimedullary arteriovenous malformations. Intraoperative ICG videoangiography confirmed the definite clipping of the fistulous points and complete removal of intramedullary arteriovenous malformations in all but one patient. All patients had satisfactory preservation of spinal cord blood supply and venous return. No adverse effects or complications related to ICG videoangiography occurred. Three patients were lost to follow up; 21 patients were followed clinically with a mean follow up of 7.5 months. The neurological deficits completely resolved in six patients, improved significantly in 10, remained stable in two, and were aggravated in three patients. Our experience shows that intraoperative ICG videoangiography offers useful information on the pathological and physiological vascular anatomy encountered during surgery for spinal vascular malformations.     

Neurointerventional procedures in the pediatric age group

Over the past 15 years there have been significant changes in the field of interventional neuroradiology, which have led to the inclusion of this specialty in the management of pediatric patients with vascular disorders of the central nervous system. Miniaturization of the devices and improvements in the embolic materials used have made it possible to perform endovascular therapy safely on neonates, infants and children. The role of endovascular therapy in the management of patients presenting with vein of Galen malformations and dural arteriovenous shunts has become clearly established. Endovascular therapists have also become important members of multidisciplinary teams managing patients with arteriovenous malformations of the brain and spinal cord. The role of endovascular therapy in the management of children with intracranial aneurysms is rapidly evolving, and experience with thrombolytic intra-arterial therapy for acute ischemic stroke is just gaining momentum. It is anticipated that in the future the role of endovascular therapy will continue to grow as part of the multidisciplinary team approach to the management of children presenting with complex vascular diseases of the central nervous system.     

Surgical treatment of spinal cord arteriovenous malformations and arteriovenous fistulas

Our objective was to review and describe operations for spinal cord arteriovenous malformations and perimedullary fistulas. We reviewed the authoritative surgical literature and added our own experience in operative considerations for these lesions. We concluded that a team approach requiring expertise in diagnostic angiography, endovascular, and microsurgical techniques is the best management strategy to optimally display and, when possible, eliminate these rare lesions. Surgical results depend on the preoperative clinical course; pathophysiology, extent, and angioarchitecture of the lesion; and experience of the surgical team.     

Use of different endovascular treatments for arteriovenous malformations of the spinal cord

The paper presents outcomes of treatment of patients with arteriovenous malformations (AVM) of the spinal cord by using endovascular techniques in 171 patients. There were a total of 364 occluded afferent vessels involved in the blood supply to and development of AVM. A classification of spinal cord AVM is presented. Methods for occlusion were described in relation to the type AVM. Malformations were thrombosed with polyvinyl acetate (PVA) emboli in 129 patients; balloon occlusion of afferent vessels was performed in 6, as described by F. A. Serbinenko; histoacryl glue was applied in 27 cases. A combined method of occlusion of afferent vessels was used with PVA emboli and balloons in 9 patients. The clinical picture of spinal cord AVM was outlined. Emphasis is laid on diagnostic methods, such as selective angiography and magnetic resonance imaging, as well as on their role in postoperative control studies, in determining the degree of thrombosis, the presence of ischemic events, and subarachnoidal space patency. Endovascular treatment used in patients with AVM at different levels of the spinal cord alleviated neurological symptoms in 155 (91%) patients. There was no improvement in 12 (7%) patients. Complications at angiography and embolization were observed with deteriorated neurological symptoms in 4 (2%) cases. Further development and improvement of endovascular treatments in patients with spinal cord will be promising if new intervention technologies are introduced in clinical practice.     

血管内栓塞术在神经外科的应用

作者对两年多来收治的106例脑、脊髓AVMs、动脉瘤和供血丰富的头、颈、颌面部肿瘤,采用不同的血管内栓塞技术和栓塞材料,进行了153例次的栓塞治疗,取得了满意的效果。治疗结果表明,不同的病变宜采用相应的栓塞技术,有利于提高血管内栓塞治疗成功率。     

非Galen静脉的脑动静脉瘘的诊断与治疗

目的探讨脑内动静脉瘘的I临床特点及经血管内栓塞与显微外科手术治疗脑内动静脉瘘的经验。方法6例经血管内栓塞治疗，1例栓塞后手术治疗，l例单纯采用显微外科手术处理瘘口。结果术后颅内杂音立即消失，临床症状显著改善。未发生严重并发症。随访5个月～2年病情无复发。结论血管内栓塞治疗可以直接准确地堵塞瘘口恢复正常的脑血液循环。在栓塞中挤压同侧或双侧颈总动脉可以降低瘘口的血流速度和压力，有益于栓塞成功。对不能采用血管内治疗的病例，手术夹闭瘘口是理想的选择。     

Spinal dural arteriovenous fistulae: exacerbation after myelography with metrizamide

Metrizamide dorsal myelography was performed in two patients with minor to moderate sensorimotor paraparesis. Direct and indirect myelographic signs of spinal arteriovenous aneurysm were seen and spinal cord angiography showed thoracic dural arteriovenous fistulae (AVF) in both cases. Within 24 hours following myelography, clear neurological worsening occurred, associated with cephalalgia, nausea and transient diplopia in one case, leading to paraplegia in a few days. Paraplegia was complete six months after surgery in one case, and had resolved after embolization of fistula in the other patient. The mechanism of neurological worsening may include: substraction of cerebrospinal fluid, sitting position during and after myelography and local increase of metrizamide concentration secondary to impaired resorption caused by the fistula. Water-soluble myelography is of invaluable aid in the diagnosis of dural AVF and must be followed by early angiography, thus allowing prompt therapeutic embolization.     

Endovascular treatment of cervical intramedullary arteriovenous malformation

Intramedullary arteriovenous malformations (AVMs) in the cervical region are a rare clinical condition. They represent a therapeutic challenge, as the lesions may cause serious functional disorders due to their location within or immediately adjacent to the critical ascending and descending sensorimotor pathways. In this case report, we present a patient with a cervical intramedullary AVM that was treated with endovascular therapy. Our experience suggests that endovascular treatment is an effective and safe method for treating AVMs located in the cervical region of the spinal cord. More studies are needed to establish appropriate treatment protocols depending on the clinical course, the anatomy of the lesion, and the region in which it is found.     

Diagnostic imaging of spinal cord lesions

Magnetic resonance imaging (MRI) has greatly facilitated morphologic evaluation of spinal cord lesions. Eleven cases representative of inflammatory, demyelinating, neoplastic and vascular diseases, are presented which illustrate and summarize important abnormal features in spinal cord imaging, particularly MR findings. Recently, specialised techniques such as MR angiography, fat-inhibiting methods, dynamic MRI and functional imaging have been developed. These methods have facilitated not only lesion diagnosis but also qualitative assessment, and are being used to analyze pathophysiology. Comprehensive diagnoses based on such modalities may be important in determining indications for surgery or defining the extent of surgery or the intensity of other treatments.