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1、Spinal Vascular Malformations Typical and Atypical FindingsContentsIntroductionClassification however, they all have a limited territory related to the radiculomeningeal artery. All radiculomedullary arteries enter the spinal canal via the nerve roots .Classification however, an acute onset of disea
2、se and a progressive development interrupted by intermediate remissions is also possible. Without therapy, this lesion results in irreversible para- or even tetraplegia.spinal venous pressure arteriovenous pressure gradient drainage of normal spinal veins venous congestion with intramedullary edema
3、(usually lower cord and conus)chronic hypoxia andprogressive myelopathySpinal dural arteriovenous fistulae (SDAVF) are the most often encountered spinal vascular malformations and account for approximately 70 % of all AV shunts of the spine.locationmechanism SDAVF misdiagnosedsymptomDural Arterioven
4、ous Fistulae The characteristic findings on MRI: Cord edema + Perimedullary dilated vessels Cord edema: centromedullary, On T2, not well delineated hyperintensity over multiple segments, often accompanied by a hypointense rim. Contrast enhancement chronic venous congestion. Perimedullary dilated ves
5、sels: typically seen on the T2 as flow voids. However, small volume shunt may only be seen after contrast enhancement. Contrast-enhanced time-resolved MRA might be helpful in locating the fistula before performing a selective spinal angiography. Spinal angiography Verify the exact height of the fist
6、ula and to rule out the fistulous type of low flow perimedullary arteriovenous malformations.Dural Arteriovenous Fistulae Treatment of SDAVF: 2 options Microsurgical treatment: is a fast, simple and definitive method with exception of sacral fistulae and should aim at occluding the feeding arterial
7、network and the proximal portion of the radicular vein. Success rates: above 95%. Endovascular therapy employing glue after superselective catheterization of the feeding radiculomeningeal artery must reach the same goal. Success rates: 25-75%.Dural Arteriovenous FistulaeFig. 1 Spinal dural AV fistul
8、a: This 74-yr-old male patient had a prolonged history of progressive gait disturbances, bowel-bladder incontinence and paraparesis.The patient underwent microsurgery(frame C, arrow at the transition zone between artery and vein) and the fistula could be occluded as confirmed by postoperative spinal
9、 angiography. The patient s clinical status had improved by his clinical follow-up visit six months later.On MRI: dilated perimedullary vessels (arrow) can be seen as flow voids. Cord edema (arrowhead). Selective spinal angiography revealed a dural fistula derived from the right Th10 segmental arter
10、y (frame B). The arrow points to the zone of fistulation underneath the pedicle.Dural Arteriovenous Fistulae Atypical findings:the following atypical findings of SDAVF in our experience with this disease based on more than 130 patients seen in our institution: delayed shunting from the epidural plex
11、us into a radicular vein (Fig. 2); the concurrence of two separate dural AV fistulae(Fig. 3); dural AV fistulae at the level of the foramen magnum(Fig. 4); the concurrence of dural AV fistulae with arteriovenous malformations of the fistulous type originating from a different segmental artery (Fig.5
12、 ). Dural Arteriovenous FistulaeFig. 2 Epidural AV fistula draining into a radicular vein: This 77-yr-old male patient was suffering from progressive gait disturbances for several months. MRI (T2TSE sequence) demonstrated findings typical for a dural AV fistula with cord edema and perimedullary enla
13、rged veins (arrows in frame A).Repeated spinal angiography at an outside institution was normal. On admission he was wheelchair-bound and had lost control of his bowel and bladder functions. During spinal angiography an epidural fistula at the right L3 level was found.Only after prolonged imaging (3
14、0 seconds) contrast media descended slowly down within the epidural plexus to the L4 level (arrows in frame B + C), crossed the midline and ascended to the L3 level where it then shunted into a left-sided radicular vein (frame D).A surgical approach was undertaken aiming to occlude both shunts. Post
15、-surgical angiography revealed occlusion of the shunt. At follow-up six months later, the patient had regained control over his bowel and bladder functions and was able to walk again.This case demonstrates the need for prolonged imaging series in selected cases of suspected spinal dural AV fistulae.
16、Dural Arteriovenous FistulaeFig. 3 Double spinal dural AV fistulae:This 70-yr-old male patient with progressive paresthesia. Surgery with confirmed occlusion of the a dural AV fistula at the right L1 level was performed in 1996. After initial regression of his symptoms, six years later he complained again of progressive weakness of his legs and bladder dysfunction.MRI of the spinal axis show
