Spinal dural arteriovenous fistula with hematomyelia caused by intraparenchymal varix of draining vein

Background ContextHemorrhage that results from spinal dural arteriovenous fistula (Type I arteriovenous malformation [AVM]) is uncommon. There are some reports of subarachnoid hemorrhage and subdural hematoma caused by Type I spinal AVM, but there are few reported cases of hematomyelia caused by spinal dural arteriovenous fistula.PurposeTo describe an interesting patient who had hematomyelia caused by a dural arteriovenous fistula (Type I spinal AVM).Study designA case report.MethodsWe present a case of a 51-year-old man who presented acute onset epigastric pain, paraplegia, and sensory loss below his nipples. Magnetic resonance imaging and selective spinal angiogram demonstrated hematomyelia, subarachnoid hemorrhage, and spinal arteriovenous fistula fed by the right Th7 intercostal artery. By laminotomy of Th6–8, the varix-like draining vein and intramedurally hematoma were partially removed and the arterial supply was interrupted by coagulation of the right Th7 segmental artery.ResultsOne month after surgery, he regained movement against gravity at the left ankle and toe but no functionally significant improvement.ConclusionsIt must be kept in mind that spinal dural arteriovenous fistulas (Type I spinal AVM) has possibility of hematomyelia origin, despite the fact that it is extremely rare.     

Two cases of spinal arteriovenous malformation presenting with subarachnoid hemorrhage

Two cases of spinal arteriovenous malformation (AVM) with subarachnoid hemorrhage (SAH) are reported. The first case is that of a 14-year-old boy who was transferred to our hospital with a sudden onset of headache. Neurological examination revealed no motosensory deficit, but a brain CT showed a slight diffuse SAH. A left vertebral angiogram demonstrated intramedullary AVM in the cervical region of the spinal cord. This AVM was therefore occluded using a solid embolization material. The patient was then discharged without neurological deficit. The second case is that of a 67-year-old man who visited our hospital with a sudden onset of headache. Neurological examination revealed no motor or sensory deficit, but a brain CT showed SAH, which was dominant in the posterior fossa. Initial cerebral angiography demonstrated no abnormality such as cerebral aneurysm or AVM except for laterality of the C1 radiculo-meningeal artery. A second angiogram on day 11 demonstrated spinal arteriovenous fistula (AVF), which was fed by the left radiculo-meningeal artery and drained to the posterior spinal vein. Embolization for the AVF was performed using liquid material. He was then discharged without neurological deficit. These two cases revealed non-specific SAH symptoms and were indistinguishable from other ruptured aneurysms. Although the brain CT can show a slight SAH or posterior fossa dominant SAH, repeated angiography may be necessary to verify and conclude the diagnosis of spinal AVM.     

Glubran-2胶用于栓塞治疗硬脊膜动静脉瘘

目的 观察以Glubran-2胶栓塞治疗硬脊膜动静脉瘘(SDAVF)的效果。方法 回顾性分析19例接受Glubran-2胶栓塞治疗的SDAVF患者,观察治疗后即刻栓塞效果、3个月后MRI表现、6个月后数字减影血管造影(DSA)表现及改良Aminoff-Logue评分,并根据后者评估疗效为稳定、改善或加重。结果 治疗后即刻造影示19例瘘口均完全封闭。治疗后1个月1例再次出现下肢无力和排尿困难,脊髓血管造影示瘘口复发,转外科治疗后病情稳定;治疗后3个月复查MRI示18例脊髓水肿范围均较治疗前明显缩小、血管流空影消失;治疗后6个月复查脊髓动脉DSA,18例均未见瘘口复发;改良Aminoff-Logue评分4.5(1.8,8.0),与治疗前[7.5(3.8,9.0)]差异有统计学意义(Z=－3.16,P<0.05),评定疗效为4例稳定、13例改善及1例加重。随访期间未见严重并发症。结论 Glubran-2胶用于栓塞治疗SDAVF效果较好。     

Paraspinal arteriovenous fistula presenting with subarachnoid hemorrhage and acute progressive myelopathy--case report

A 60-year-old man presented with paraspinal arteriovenous fistula (AVF) manifesting as subarachnoid hemorrhage (SAH) and acute progressive myelopathy. The patient presented with sudden onset of low back pain and paraparesis. Spinal magnetic resonance imaging revealed a vascular malformation on the lumbar spinal canal. Three-dimensional computed tomography angiography demonstrated a paraspinal AVF in the sacral ventral pelvis. The clinical symptoms were progressing rapidly, so transarterial embolization and surgical drainage ligation were performed. Paraspinal AVF may present with SAH and cause acute progressive myelopathy. Prompt examination and treatment are necessary.     

A case report of arteriovenous malformation of the tongue: vascular anatomy and note for transarterial embolization

Arteriovenous malformation (AVM) of the tongue is a rare lesion of the cranio-facial vascular anomaly. Decision making concerning the vascular anomaly is not established because there are complex classifications of diagnosis and many treatment options. We report a case of AVM of the tongue, and review vascular anatomy and knowledge for treating this lesion. A 50-year-old man presented with dysarthria, sleep apnea and snoring because of a mass lesion of his sublingual region that had become larger over a two-year period. Neuroradiological examination revealed lingual arteriovenous fistula (AVF) associated with AVM of the tongue base. We performed transfemoral transarterial embolization via both lingual arteries using Polyvinyl alcohol particles and Eudragit-E as non-adhesive glue material. Final angiograms after embolization revealed a small residual nidus fed by the right facial artery mental branch, but shunt flow was markedly reduced. This vascular malformation was removed after a day of TAE (transarterial embolization). The patients symptom was improved and relapse has not been confirmed though 18 months have passed since the surgery. Using classification proposed by Mulliken and Glowacki, vascular anomalies are divided into two groups: hemangiomas and vascular malformations (AVM/F, arterial, venous, capillary, lymphatic and combined). AVM/F is classified into high flow malformation. TAE is useful for high flow malformation and can be used as the sole treatment or as an adjunct. Treatment should be to eradicate nidus or fistula completely, which is the fundamental abnormality because even the smallest residual nidus will expand to cause recurrence. The treatment of Cranio-facial AVM's requires rigorous differential diagnosis and appropriate management. Inadequate treatment is thought to contribute to collateral flow and disease progression in advanced AVM, making further management difficult.     

A case of dural arteriovenous fistula of the inferior petrosal sinus successfully treated by transarterial and transvenous embolizations

A 69-year-old male was admitted with chemosis and exophthalmos of his right eye. Angiograms revealed a dural arteriovenous fistula (AVF) involving the right inferior petrosal sinus. The AVF was fed by the right occipital and ascending pharyngeal arteries and drained into the cavernous sinus and right superior ophthalmic vein from the right inferior petrosal sinus. He was treated by transarterial embolization with polyvinyl alcohol in order to reduce the shunt-flow through the fistula. Then he was treated by transvenous embolization with GDC coils five days after the arterial embolization. Symptoms in his right eye have completely disappeared. Transvenous embolization combined with transarterial embolization is a useful and safe approach in the management of AVF involving the inferior petrosal sinus.     

Incidental discovery of a long standing arteriovenous fistula after thrombectomy for acute lower limb ischaemia

INTRODUCTION

Arteriovenous fistula (AVF) is the abnormal connection between an artery and vein. Congenital AVF of the popliteal artery is very rare.

PRESENTATION OF CASE

89 year old lady presented with right acute lower limb ischaemia. She had unilateral chronic venous hypertensive change in the right leg. Femoral embolectomy was performed. Backflow was achieved. Arteriotomy was closed. The patient''s leg continued to deteriorate. She returned to theatre. On-table angiogram showed an occluded SFA. Thrombectomy was completed. SFA was patent but no blood flowed into the distal popliteal artery. A second on table angiogram revealed AVF between popliteal artery and vein. Dissection to the posterior aspect of the knee revealed the fistula. The vein was arterialized and enlarged. The AVF was ligated. Normal distal blood flow was achieved. Retrospectively we measured the leg lengths. Right leg was 3 cm longer than the left. The right leg circumference was 7 cm greater than the left. She reported chronic venous change from a young age. She did not report any history of trauma to the limb.

DISCUSSION

Popliteal artery to popliteal vein fistula is a rare. Trauma is the most common cause of popliteal AVF. Should the condition develop before closure of the epiphyses, there may be an increase in leg measurements.

CONCLUSION

We postulate that this case of AV fistula may be congenital due to discrepancy in leg measurements and unilateral chronic venous hypertensive change. Rarely persistent remnants of the embryonic sciatic artery can lead to arteriovenous anastomoses, which may be a possible aetiology.     

Development of a cerebral arteriovenous malformation documented in an adult by serial angiography. Case report

This 61-year-old man with a right-sided tentorial dural arteriovenous fistula (DAVF) was initially treated with staged stereotactic radiosurgery and transarterial embolization. Results of follow-up cerebral angiography performed 4 years later demonstrated complete obliteration of the dAVF and development of a previously undetected cerebellar arteriovenous malformation (AVM). The newly diagnosed AVM was treated with repeated stereotactic radiosurgery. This represents the first reported case of the development of a cerebral AVM documented in an adult by serial angiography.     

Coil embolization of vertebro-vertebral arteriovenous fistula: a case report

BACKGROUND: Vertebro-vertebral arteriovenous fistulas (VVFs) are not uncommon, but they usually present with benign symptoms such as neck murmur. We report a case of VVF presenting with myelopathy which was successfully treated by embolization with detachable coils. CASE PRESENTATION: A 72-year-old woman was admitted with complaint of bilateral leg weakness. Cervical magnetic resonance image showed compression of the spinal cord by a large vascular lesion. Right vertebral angiogram showed a vertebro-vertebral fistula draining into ectatic epidural veins. From a transfemoral arterial approach, the fistula site was selected with a microcatheter, and embolization was performed by placement of several Guglielmi detachable coils until flow arrest was obtained. The patient made a full recovery, and long-term angiographic follow-up demonstrated complete cure. CONCLUSION: We present a case of VVF treated using detachable coils with good long-term results.     

Transcatheter coil embolization of an iatrogenic superior mesenteric arteriovenous fistula: Report of a case

A 37-year-old male patient presented with abdominal pain and diarrhea. Computed tomography showed a large superior mesenteric vein aneurysm. The patient had a history of Crohn’s disease and underwent an ileocecal resection 7 years previously. A selective angiogram of the superior mesenteric artery revealed that a dilated branch of this artery fed directly into the superior mesenteric vein. The iatrogenic superior mesenteric arteriovenous fistula was successfully closed by transarterial coil embolization. Successful endovascular treatment for a superior mesenteric arteriovenous fistula has been recently reported; however, the complications of this new modality are not well understood. We herein review the current literature and discuss endovascular treatment.     

Endovascular treatment for acute paraplegia after epidural steroid injection in a patient with spinal dural arteriovenous malformation

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal arteriovenous malformations. Type 1 spinal arteriovenous malformations are defined by the presence of radiculomeningeal feeders that drain into intradural veins. Patients with these lesions frequently present with chronic myelopathy, which is most often caused by venous hypertension. The authors present the case of a 69-year-old man with acute paraparesis following a lumbar epidural injection, resulting from a previously undiagnosed SDAVF. The patient initially reported right lower-extremity weakness and paresthesias and was referred to an orthopedic practice. His pain and weakness were exacerbated with ambulation. Reevaluation at 4 months was remarkable for groin, mild low-back, and buttock pain. The patient received a right L5-S1 interlaminar epidural steroid injection and became acutely weak. He presented to the emergency department 3 hours after the injection. Once MRI of the lumbar and thoracic spine had been performed, the neurosurgery service was consulted, and it was decided to proceed with emergent spinal angiography with the intent to embolize the fistula. An emergent spinal angiogram was obtained, revealing 2 arterial pedicles emanating from the right T-5 and T-6 radicular arteries. Transarterial embolization was thought to be the most rapid way to potentially obliterate the fistula. The patient exhibited immediate improvement in neurological function, and by 6 hours postprocedure, his neurological function was near normal. He was ambulatory and released to home 3 days after the embolization procedure.     

Thrombosis of a spinal arteriovenous malformation after hemorrhage: case report

BACKGROUND: Thrombosis of cerebral arteriovenous malformations (AVM) and spinal dural arteriovenous fistulas following hemorrhage rarely have been reported. Rarer still is thrombosis of spinal AVMs following hemorrhage. CASE DESCRIPTION: A 6-year-old boy presented with sudden low back and sciatic pain, bilateral leg weakness, and an intramedullary spinal cord hematoma. Spinal angiography demonstrated dilated feeding arteries without shunting, and no intervention was performed. Over time, these enlarged arteries reduced in caliber, and the patient recovered fully. CONCLUSIONS: The rarity of spinal AVMs and AVM thrombosis make their coincidence in this case unique. Although surgical intervention would have enabled definitive diagnosis of the spinal AVM, it is not mandatory in the absence of arteriovenous shunting. What is mandatory, however, is continued angiographic surveillance, particularly in pediatric patients.     

Arteriovenous malformation of the conus supplied by the artery of Desproges-Gotteron

The artery of Desproges-Gotteron is rarely mentioned in the literature and is unfamiliar to most neurosurgeons. The authors report a unique case of an arteriovenous malformation (AVM) of the conus in an adult woman, which received blood supply from an artery of Desproges-Gotteron. The patient presented with intermittent pain radiating down the right posterior thigh and foot and transient bladder incontinence. On examination, there was weakness of the right lower limb with hypalgesia of the plantar aspect of the right foot. Magnetic resonance imaging revealed a mass near the anterior aspect of the conus medullaris and angiography confirmed a spinal AVM at the L-1 level and a shunt located at the inferior L-3 level. The patient underwent transarterial embolization, and at 2-year follow-up, repeat angiography demonstrated no evidence of residual or recurrent spinal AVM, intermittent and tolerable pain without treatment interventions, and a normal neurological examination. The artery of Desproges-Gotteron appears to be a rare arterial variation. Moreover, the authors believe this to be the first case of a conal AVM supplied by such an artery. The anatomy and implications of such an arterial variant are discussed.     

Intraoperative Angiography Using Portable Fluoroscopy Unit in the Treatment of Vascular Malformation

Intraoperative angiography (IOA) is employed for the treatment of the complicated cases in neurological surgery. The IOA is usually performed with OEC portable digital subtraction angiography (DSA) unit. We are performing IOA with portable fluoroscopy unit with simple DSA function and report its usefulness on neurosurgical treatment. IOA or hybrid treatment with mobile fluoroscopy system was performed for 9 cases [cerebral arteriovenous malformation (AVM), 3; cranial dural arteriovenous fistula (AVF), 2; and spinal AVM/AVF, 4]. Thus, ex vivo analysis was performed comparing image quality of portable fluoroscopy unit and conventional DSA system. Although the resolution of portable fluoroscopy unit is not so high compared to conventional DSA system, the existence of the vascular lesions such as cerebral aneurysm, cerebral AVM, and spinal dural AVF were detected. The operation of portable fluoroscopy unit was simple and no special assistance was required. The complication related to the catheterization or IOA did not occur. IOA with portable fluoroscopy unit was useful for the identification of vascular lesion and has advantage on the cost benefit.     

Surgical Management of Combined Intramedullary Arteriovenous Malformation and Perimedullary Arteriovenous Fistula within the Hybrid Operating Room after Five Years of Performing Focus Fractionated Radiotherapy: Case Report

Perimedullary arteriovenous fistula (AVF) shunts occur on the spinal cord surface and can be treated surgically or by endovascular embolization. In contrast, the nidus of an intramedullary arteriovenous malformation (AVM) is located in the spinal cord and is difficult to treat surgically or by endovascular techniques. The benefits of radiotherapy for treating intramedullary AVM have been published, but are anecdotal and consist largely of case reports. We present a case of combined cervical intramedullary AVM and perimedullary AVF which received surgical treatment within a hybrid operating room (OR) after 5 years of focus fractionated radiotherapy. A 37-year-old male presented with stepwise worsening myelopathy. Magnetic resonance imaging and spinal angiography revealed intramedullary AVM and perimedullary AVF at the C3 to C5 levels. In order to reduce nidus size and blood flow, we first performed focal fractionated radiotherapy. Five years later, the lesion volume was reduced. Following this, direct surgery was performed by an anterior approach using corpectomy in the hybrid OR. The spinal cord was monitored by motor-evoked potential throughout the surgery. Complete obliteration of the fistulous connection was confirmed by intraoperative indocyanine green video-angiography and intraoperative angiography, preserving the anterior spinal artery. We conclude that surgical treatment following focal fractionated radiotherapy may become one strategy for patients who are initially deemed ineligible for endovascular embolization and surgical treatment. Furthermore, the hybrid OR enables safe and precise treatment for spinal vascular disorders in the fields of endovascular treatment and neurosurgery.     

A case of vein of Galen aneurysmal malformation with a newly developed dural arteriovenous fistula after successful embolization

We report a case of vein of Galen aneurysmal malformation (VGAM) with a newly developed dural arteriovenous fistula (AVF) subsequent to successful embolization. A male neonate diagnosed as VGAM with prenatal ultrasonography and MRI presented severe cardiac and respiratory failure soon after birth. Five sessions of transarterial embolization using NBCA were performed during the first 6 months of his life. The shunt flow was effectively reduced and heart failure was resolved after the treatment. Follow-up angiography performed 2.5 years after the last embolization revealed complete obliteration of VGAM and newly developed small dural AVF on the wall of the thrombosed falcorial sinus. We believe that the dural AVF in this case was caused by local venous hypertension or induction of angiogenic factor during the thrombosing process of VGAM.     

Usefulness of dynamic MRA and CTA in diagnosis and postoperative evaluation in spinal dural arteriovenous fistula: a case report

Here we report a case of spinal dural arteriovenous fistula that was diagnosed on MRA and CTA, and then treated by endovascular embolization. A 56-year-old male presented with slowly progressive intermittent claudication and numbness of the lower extremities. T2-weighted MR imaging showed the swelling of the spinal cord with an intramedullary high signal intensity area and dilated vessels with signal flow void at the dorsal aspect of spinal cord. Dynamic MRA demonstrated the feeding artery, shunt point and the overview of dilated veins as seen with a CTA. Endovascular embolization using liquid material was performed under local anesthesia. The injection of glue included the distal feeding artery, the shunt itself and the initial part of the draining vein. A complete cure was achieved. CTA after embolization demonstrated the glue cast and the disappearance of the AV shunt and dilated veins that were visible before embolization. It was suggested that dynamic MRA and CTA are useful for the final diagnosis and postoperative evaluation of spinal dural arteriovenous fistulas.     

Sudden hypertension in a kidney transplant recipient after a skiing accident

IntroductionComplications after renal transplants are frequent. A well-known but less frequent complication is arteriovenous fistula formation, which can remain asymptomatic or present with hematuria, hypertension, or renal insufficiency.Presentation of caseWe present the case of a young, male kidney transplant recipient with newly developed hypertension due to the formation of an arteriovenous fistula a long period after the last renal biopsy.DiscussionIn our case, the sonographic evaluation showed the aliasing phenomenon, which was useful in the detection of the AVF. Superselective transcatheter embolization is considered to be the treatment of choice in such cases and has been proven to be safe and effective, even in long-term evaluations.ConclusionOur findings in this case highlight a rarely reported clinical presentation which physicians should be aware of when evaluating patients who have received a renal transplant.     

Endovascular trapping using a tandem balloon technique for a spontaneous vertebrovertebral fistula associated with neurofibromatosis type 1

We report a rare case of a young man who had spontaneous left vertebrovertebral fistula associated with neurofibromatosis Type 1. His complaints were severe pain in the left neck and numbness in the left upper extremity. Cervical MR images showed a large abnormal flow void to the left of the spinal canal. An angiogram demonstrated a fusiform aneurysm and a high flow arteriovenous fistula in the left vertebral artery that drained into the internal vertebral plexus and formed a large venous varix. The occipital artery, the thyrocervical artery and the contralateral vertebral artery were associated with the fistula. The arteriovenous fistula was treated by endovascular coil embolization, using a tandem balloon technique. For this fistula, exhibiting the combination of high flow and multiple associated arteries, the flow control technique during the coil embolization, using tandem balloons in both the subclavian artery and the distal portion of the fistula of the vertebral artery, was safe and feasible for preventing coil migration.