Treatment Of Spinal Arteriovenous Malformations Research Articles

The utility of intraoperative neurophysiological monitoring in surgical treatment for spinal arteriovenous malformations: A historical control study

ObjectiveThis study sought to investigate the utility of intraoperative neurophysiological monitoring (IONM) in the surgical treatment for spinal arteriovenous malformations (SAVMs). MethodsWe retrospectively reviewed the data of 39 patients who underwent surgical treatment for SAVMs. Twenty-eight patients who received multimodal IONM (transcranial electrical motor-evoked potentials [MEPs], somatosensory-evoked potentials, continuous electromyography, and bulbocavernosus reflex [BCR]) between 2011 and 2020 were compared to 11 historical controls between 2003 and 2011. The rates of postoperative neurological deficits (PNDs), neurophysiological warnings, and their characteristics were analyzed. ResultsPNDs were developed in 10.7% and 54.5% of patients in the IONM and historical control (non-IONM) groups, respectively (p = 0.008). Moreover, not applying IONM was the only significant risk factor for the development of PNDs in the logistic regression analysis (odds ratio 10.0, p = 0.007). In the IONM group, a total of three electrophysiological warnings were observed, and two of these were true positives; one patient complained of leg motor weakness after surgery with loss of the abductor halluces MEPs. The other patient experienced disappearance of the BCR during surgery and newly developed urinary retention. Overall, the sensitivity, specificity, positive predictive value, and negative predictive value of IONM warnings for detecting PNDs were 66.7%, 96.0%, 66.7%, and 96.0%, respectively. ConclusionsThe neurological outcome of the IONM group was significantly better than that of the historical control group in the surgical treatments for SAVMs. SignificanceMultimodal IONM could be a useful tool to detect neurological damage with relatively high accuracy in this type of surgery.

Clinical and angiographic results of long-term follow-up of patients after endovascular treatment for spinal arteriovenous malformations

Objective – to evaluate long-term results of treatment of patients with arteriovenous malformations AVM of the spinal cord. Materials and methods. A retrospective analysis of clinical and angiographic data of the results of treatment of patients with spinal AVM for the period from 2005 to 2019 was conducted. In SO «Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine» 47 patients were operated on endovascular method. The age of patients ranged from 11 to 62 years (middle age is 45.3 years). There were 29 men (61.7 %), 18 women (38.3 %). Liquid cyanoacrylate embolizant was used for endovascular intervention. The operations were performed with transfemoral access. Accoding the classification proposed by Anson and Spetzler in 1992 patients with type I were 31 (65.9 %), with ІІ type – 8 (17.0 %), with ІIІ type – 5 (10.6 %), with IV type – 3 (6.4 %). Magnetic resonance tomography and spinal angiography were used for diagnostics AVM.Results. Total exclusion of AVM from the bloodstream was achieved in 22 (46.8 %) cases. Out of the 31 (65.9 %) patients with type I AVM, 17 (54.8 %) had an early transient deepening of the neurological deficit. In this group, complete dissection of arteriovenous fistula was achieved in 16 (51.6 %) patients. In 8 (17.0 %) patients with type II AVM, complete exclusion of AVM was achieved in 5 (62.5 %) cases. In this case, 6 (75.0 %) patients were observed early postoperative deepening of neurological symptoms. In 5 (10.6 %) patients with type III AVM, total exclusion was achieved in 1 (20.0 %) case. Transient deepening of neurological deficit was noted in 3 (60.0 %) patients. In 3 (75.0 %) patients with type IV AVM, total embolization was achieved in 1 (33.0 %) observation. Neurological impairment occurred in 1 (33.0 %) patient. In all groups there were no fatalities.Conclusions. Angiography is the gold standard of diagnosis and dynamic monitoring of patients with spinal cord AVM. The use of endovascular treatment of AVM can stop the further progression of neurological deficits, which, however, is not always associated with the total exclusion of AVM. The best neurological improvement and total exclusion were achieved in patients with type I AVM. Radicality, efficacy and deepening of neurological deficiency depend on angioarchitectonics of AVM. The main condition for carrying out embolization is to achieve a safe level of catheterization of the afferent.

A rare case of treatment of Giant paravertebral arteriovenous malformation combined with idiopathic scoliosis

The paper describes a case of successful treatment of a 32-year-old female patient with idiopathic scoliosis combined with giant paravertebral arteriovenous malformation in the lower thoracic region, causing the T11 vertebral body destruction, circular epidural compression, and myelopathy. The treatment was performed using 3D printing technology and hybrid surgery. The follow-up period after the first surgery was 26 months. The case report is accompanied by a literature review that analyzes world experience in the treatment of spinal arteriovenous malformations.

Endovascular and microsurgical treatment for spinal arteriovenous malformations. Our experience

Objective – to improve the treatment quality for patients with spinal arteriovenous malformations (AVM).Materials and methods. A retrospective analysis of endovascular and surgical treatment of patients was made. In SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» since 2005 till 2018 were operated 55 patients (34 (61.8 %) men and 21 (38.2 %) women). The age of patients ranged from 11 to 62 years (middle age is 45.3 years). The classification proposed by Anson and Spetzler in 1992 was used in order to divide patients into experimental groups: type I, arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile AVM; and type IV, perimedullary AVF. Patients with type I were 36 (65.5 %), with ІІ type – 10 (18.2 %), with ІIІ type – 5 (9.0 %), with IV type – 4 (7.3 %). For diagnostics were used MRI and spinal angiography. The Aminoff–Logue scale was used for assessment of the neurological deficiency severity. Early postoperative complications (CSF) leakage, wound infection, early postoperative worsening) were counted.Results. 12 (21.8 %) patients were treated using the microsurgical method and 43 (78.2 %) were treated endovascular. We used endovascular and microsurgical methods to treat patients with I type spinal AVM. Microsurgical intervention for 9 (33 %) patients was performed. Complete disconnection of fistula was achieved in 9 patients. Early postoperative complication (CSF leakage) was observed in 1 (11 %) case. Endovascular treatment was performed for 27 (67 %) patients. Total disconnection was achieved in 16 (59 %) cases, 17 patients (63 %) had early transient neurological worsening. Embolization is the first-line treatment for patients with type II AVM – 8 (80 %) patients. Complete obliteration of AVM was attained in 5 patients (62.5 %), 6 (75 %) patients suffered from early worsening of postoperative neurological symptoms. The microsurgical method was used in case of low risk of spinal cord injury in 2 patients (20 %), AVMs were excluded totally in 2 patients and in 1 patient neurological deterioration was stabilized. All patients with III type AVM were treated endovascular. AVM was obliterated complete in 1 patient (20 %). Three (60 %) patients had transient neurological deterioration. Endovascular method was used to treat 3 (75 %) patients with type IV AVM. Totally disconnection of AVM was achieved in 1 (33 %) patient. Super-selective catheterization of all conductive arteries was not possible. Neurological worsening was observed in 1 (33 %) patient.Conclusions. Angiography is the first-line diagnostic method which permits to find the most effective and safe way (endovascular or/and microsurgical treatment) to disconnect AVM from spinal cord bloodstream. Microsurgical intervention helps to achieve eye-controlled total arteriovenous disconnection. Microsurgical technique usage leads to good neurological results – neurological improvement the following day after surgery in all cases of AVM type I treatment. The structure of AVM determines effectiveness, radicality, method of treatment and the level of feeder artery catheterization. The main goal of embolization to achieve the safe catheterization level of the afferent. Multimodal treatment, which includes endovascular and microsurgical methods, is the most effective in case of AVM II and III types.

Stereotactic radiosurgery and fractionated radiotherapy for spinal arteriovenous malformations – A systematic review of the literature

Spinal arteriovenous malformations (AVMs) comprise a group of complex vascular lesions whose treatment with microsurgery or transarterial embolization can be challenging. Stereotactic radiosurgery is a well-established treatment for intracranial AVMs, and spinal radiosurgery and fractionated radiotherapy are common treatments for spinal tumors of both primary and metastatic origin. The use of radiosurgery and fractionated radiotherapy for the treatment of spinal arteriovenous malformations, however, has been infrequently reported. Spinal stereotactic radiosurgery is emerging as a promising option for the treatment of these lesions. We conducted a systematic review of English language articles reporting one or more cases of spinal radiosurgery or fractionated radiotherapy for the treatment of spinal arteriovenous fistulas (AVFs) or arteriovenous malformations. Eight unique studies comprising 64 patients were identified. All treated lesions consisted primarily of spinal AVMs, either intramedullary or metameric. Most were treated with CyberKnife technology. Marginal doses in the most current studies ranged from 18 to 21 Gy given over 2–4 fractions. In aggregate, good outcomes were reported in 92.2% with no instances of post-treatment hemorrhage over a mean follow-up time of 46.8 months. Angiographic follow-up showed the nidus to be obliterated in 16%, decreased in 44.6%, and unchanged in 39.3%. Stereotactic radiosurgery for spinal arteriovenous malformations holds promise as a safe and potentially effective option in the treatment of these rare but complex lesions.

Surgical and Endovascular Treatment for Spinal Arteriovenous Malformations.

Spinal arteriovenous malformation (AVM) is a broad term that constitutes diverse vascular pathologies. To date, various classification schemes for spinal AVM have been proposed in literature, which helped neurosurgeons understand the pathophysiology of the disease and determine an optimal treatment strategy. To discuss indications and results of surgical and endovascular interventions for spinal AVM, this article refers to the following classification proposed by Anson and Spetzler in 1992: type I, dural arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile malformations; and type IV, perimedullary AVF. In general, complete obliteration of the fistula is a key for better outcome in type I dural and type IV perimedullary AVFs. On the other hand, in type II glomus and type III juvenile malformations, functional preservation, instead of pursuing angiographical cure, is the main goal of the treatment. In such cases, reduction of the shunt flow can alleviate clinical symptoms. Proper management of spinal AVM should start with neurological examination and understanding of angioarchitectures, which provide critical information that guides the indication and modality of intervention. Finally, close collaboration of the microsurgical and endovascular teams are mandatory for successful treatment.

Endovascular Treatment of Spinal Arteriovenous Malformations

Background: Spinal arteriovenous malformations (AVMs) are a rare and enigmatic disease entity. These lesions can be a significant cause of myelopathy and their initial symptoms mainly include sensory loss and motor weakness. The treatment of spinal AVMs has improved tremendously. However, the choice between surgical treatment and embolization remains a matter of debate. Objectives: The aim of this study is to investigate the outcome of the endovascular management of these lesions. Patients and Methods: We report on 18 patients with spinal-AVM in whom the diagnosis was confirmed by using spinal-MRI/angiography. Patient age ranged from 19 to 73 years. All patients underwent embolization with glue/onyx. Before and after the operation, patients were followed using Aminoff Logue scale to measure clinical outcome and spinal-MRI to evaluate the feature of the lesion. Results: There was significant difference between the clinical scores (based on AminoffLogue scale) of before and after operations (P < 0.01). This significant change is seen in both short and long-term follow-up. Temporary clinical deterioration was found in one patient. Our data showed that the efficacy of this method in long-term follow-up is about 90%. Conclusions: Endovascular embolization is an effective therapeutic procedure in the treatment of spinal AVMs.

Late spinal dislocation after treatment of spinal arteriovenous malformation: A case of Charcot spinal arthropathy

Neuropathic arthropathy of the spine is a destructive condition of the spine which is secondary to a loss of the protective proprioceptive reflexes. In the majority of cases, it occurs in patients who have suffered from traumatic medullary lesions and is responsible for destruction of the vertebral bodies and considerable spinal deformity. We report a case of neurogenic lumbar arthropathy in a patient with a spinal arteriovenous malformation. This vascular lesion caused considerable disturbances of proprioception. The course was favorable with regard to the deformity after correction and fusion by posterior approach.

Intraventricular hemorrhage as a false localizing sign of a thoracolumbar arteriovenous malformation: case report

BACKGROUND Spinal arteriovenous malformation (SAVM) is a relatively rare disease characterized by a high incidence of intramedullary and subarachnoid haemorrhage. When the hemorrhage is profuse and the SAVM is in the cervical region the symptoms (disturbance of consiousness, papilledema, cranial nerve palsies, and convulsions) may be so severe and rapid in their onset that they may be mistaken for intracranial hemorrhage. We report here on a patient with a SAVM at T10–12, which bled intracranially, mainly intraventricularly, and resulted first in respiratory arrest and unconsciousness. CASE DESCRIPTION The patient had been well until he was 28 years old when, during intercourse, he suffered a terrible headache and suddenly lost consciousness, with a transient respiratory arrest. He was also noted to have right hemiparesis. A computed tomography scan demonstrated intraventricular hemorrhage. After a 24-hour period of artificial ventilation the patient regained consciousness and the right arm paresis completely recovered, but a gradual worsening of the motor function of the left leg developed. Digital subtraction angiography did not demonstrate any intracranial source of bleeding, whereas spinal angiography revealed a SAVM located at the medullary cone, which was totally removed by surgery. CONCLUSION The case reported here raises several important issues. First, the advisability of spinal magnetic resonance imaging in the investigation of intraventricular (and subarachnoid) hemorrhage in patients with no demonstrable intracranial source. Secondly, the benefits of early diagnosis and reestablishment of the spinal cord circulation before the onset of thrombosis and the progressive phase of myelopathy. Finally, the necessity of complete obliteration and treatment of SAVMs even in patients with fixed neurologic deficits, because rebleeding of lower thoracic or lumbar SAVMs can lead to impairment at a higher level with severe or lethal consequences.

Outcome From Treatment For Spinal Arteriovenous Malformation

Our knowledge of the outcome from treatment for spinal arteriovenous malformations (AVMs) is limited to a few small, anecdotal series and is thus far from complete. Furthermore, with the recent rapid evolution of our knowledge of AVM pathology, many reported cases are difficult to place in the current classification system. In general, outcome for the four classifications of AVMs are as follows: type I respond well to surgical disconnection of the arteriovenous fistula if treatment is early; type II AVMs are currently best treated by surgery but risks of a poor outcome need to be carefully considered; type III are only rarely treatable; type IVa and IVb are likely to respond well to surgery but our knowledge is limited; and type IVc are likely to fare poorly from surgery but should have a better outcome from endovascular therapy.

Hemodynamic evaluation of spinal arteriovenous malformations before and after embolization--preliminary report.

This preliminary study investigated local hemodynamic changes in intramedullary spinal arteriovenous malformation (AVM) before and after embolization. 99mTcO4- was injected into the anterior spinal artery feeding the AVM via a Tracker-10 or MAGIC microcatheter. Time-dependent radioisotope images were sequentially obtained in the anteroposterior plane every 0.2 sec before and just after embolization. Local mean transit time (MTT) was then calculated for both the nidus and draining vein and compared before and after embolization. Prior to embolization, MTTs in the nidus and in the draining vein were 1.84 +/- 0.62 (mean +/- SD) and 2.80 +/- 0.69 sec for the five patients, respectively. MTTs in both the nidus and the draining vein were significantly prolonged after embolization to 3.32 +/- 1.14 and 4.90 +/- 0.93 sec, respectively (p < 0.02 and p < 0.005, respectively). In vivo measurements of local hemodynamic changes in the spinal cord during the treatment of spinal AVMs could be achieved. This method may allow investigation of the hemodynamic mechanisms which induce ischemic symptoms in patients with spinal AVM.

Intravascular treatment of spinal arteriovenous malformations using a microcatheter—With special reference to serial xylocaine tests and intravascular pressure monitoring

Spinal arteriovenous malformations (spinal AVMs) are now treated using microcatheters and various embolic materials. Interventional techniques of this type are thought to be the first choice for treatment of spinal AVMs. In this study, we used the Tracker vascular access system and MAGIC catheter for intravascular treatment of spinal AVMs in order to avoid proximal occlusion. Notably, serial provocation tests using xylocaine (20 mg in bolus) and intermittent intravascular pressure monitoring in the anterior spinal artery were conducted during embolizations of five intramedullary AVMs. We used 150–350 μm polyvinyl alcohol particles (Ivalon) and/or polyvinyl alcohol (PVA) solutions as embolic materials for occlusion of these AVMs. Vital signs and neurologic functions were carefully monitored during and after the procedure. We were able totally to obliterate the nidus or markedly to reduce its size while preserving the anterior spinal artery in each of the patients. The xylocaine test was conducted an average of 2.6 times (2–4 times) during embolization. For the two patients who were treated with Ivalon and PVA solutions, the final provocation test became positive, and the embolization procedure was terminated. On the other hand, the remaining patients had a positive result on first xylocaine test and were treated with Ivalon alone. At the same time, intravascular pressure monitoring was performed via the microcatheter, which was located in the anterior spinal artery. The value of the intravascular systolic pressure prior to embolization was 71.6 ± 14.1 mm Hg and it gradually increased during the procedure, and reached 99.6 ± 12.6 mm Hg (90% of the systemic systolic blood pressure) by the conclusion of embolization. Serial xylocaine tests and intravascular pressure monitoring may be useful for the treatment of spinal AVMs fed mainly by the anterior spinal artery, and embolization with liquid embolic material should be terminated when the provocation test becomes positive and intravascular pressure increased to 90% of the systemic blood pressure.