Spinal extradural arteriovenous malformations with parenchymal drainage

Venous drainage variability and implications in clinical manifestations

Michelle J. Clarke, Todd A. Patrick, J. Bradley White, Harry J. Cloft, William E. Krauss, E. P. Lindell, David G. Piegras

Research output: Contribution to journalArticle

43 Citations (Scopus)

Abstract

Object. Although nontraumatic spinal arteriovenous malformations and fistulas (AVMs and AVFs) restricted to the epidural space are rare, they can lead to significant neurological morbidity. Careful diagnostic imaging is essential to their detection and the delineation of the pathological anatomy. Aggressive endovascular and open operative treatment can provide arrest and reversal of neurological deficits. Methods. The authors report on 6 cases of extradural AVMs/AVFs causing progressive myelopathy. Clinical findings, diagnostic evaluation, treatment, and outcome are discussed. Special consideration is given to the anatomy of the lesions and the operative techniques used to treat them. A review of the literature concerning extradural vascular malformations is also presented. Results. All 6 cases of extradural AVMs had an extradural fistulous location with intradural medullary venous drainage. These cases illustrate progressive myelopathy through cord venous congestion (hypertension) that can be caused by an extradural nidus or fistula. In 4 cases, a large epidural lake was identified on angiography. At surgery, the epidural lake was obliterated and medullary drainage interrupted. All patients had stabilization of their neurological deficits and successful obliteration of the AVM/AVF was obtained. Conclusions. Extradural AVMs and AVFs are a poorly described entity with published clinical experience limited to sporadic case reports and small series. Although these lesions have a purely extradural location of arteriovenous shunting and early venous drainage, they can be responsible for acute and progressive neurological symptoms similar to those caused by their dural-based intradural counterparts. With careful imaging recognition of the pathological anatomy, surgical and endovascular techniques can be used for the treatment of extradural AVMs affording effective and durable obliteration with stabilization or reversal of neurological symptoms. Venous drainage directly correlates the pathologic mechanisms of presentation. Specific attention must be paid intraoperatively to the epidural lake common to both variants so that recurrence is avoided.

Original languageEnglish (US)
JournalNeurosurgical Focus
Volume26
Issue number1
DOIs
StatePublished - 2009

Fingerprint

Arteriovenous Malformations
Drainage
Lakes
Anatomy
Spinal Cord Diseases
Epidural Space
Endovascular Procedures
Vascular Malformations
Arteriovenous Fistula
Hyperemia
Diagnostic Imaging
Fistula
Angiography
Hypertension
Morbidity
Recurrence
Therapeutics

Keywords

  • Dural arteriovenous fistula
  • Extradural arteriovenous malformation
  • Intraspinal angioma
  • Spinal arteriovenous fistula
  • Spinal arteriovenous malformation

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Spinal extradural arteriovenous malformations with parenchymal drainage : Venous drainage variability and implications in clinical manifestations. / Clarke, Michelle J.; Patrick, Todd A.; White, J. Bradley; Cloft, Harry J.; Krauss, William E.; Lindell, E. P.; Piegras, David G.

In: Neurosurgical Focus, Vol. 26, No. 1, 2009.

Research output: Contribution to journalArticle

Clarke, Michelle J. ; Patrick, Todd A. ; White, J. Bradley ; Cloft, Harry J. ; Krauss, William E. ; Lindell, E. P. ; Piegras, David G. / Spinal extradural arteriovenous malformations with parenchymal drainage : Venous drainage variability and implications in clinical manifestations. In: Neurosurgical Focus. 2009 ; Vol. 26, No. 1.
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abstract = "Object. Although nontraumatic spinal arteriovenous malformations and fistulas (AVMs and AVFs) restricted to the epidural space are rare, they can lead to significant neurological morbidity. Careful diagnostic imaging is essential to their detection and the delineation of the pathological anatomy. Aggressive endovascular and open operative treatment can provide arrest and reversal of neurological deficits. Methods. The authors report on 6 cases of extradural AVMs/AVFs causing progressive myelopathy. Clinical findings, diagnostic evaluation, treatment, and outcome are discussed. Special consideration is given to the anatomy of the lesions and the operative techniques used to treat them. A review of the literature concerning extradural vascular malformations is also presented. Results. All 6 cases of extradural AVMs had an extradural fistulous location with intradural medullary venous drainage. These cases illustrate progressive myelopathy through cord venous congestion (hypertension) that can be caused by an extradural nidus or fistula. In 4 cases, a large epidural lake was identified on angiography. At surgery, the epidural lake was obliterated and medullary drainage interrupted. All patients had stabilization of their neurological deficits and successful obliteration of the AVM/AVF was obtained. Conclusions. Extradural AVMs and AVFs are a poorly described entity with published clinical experience limited to sporadic case reports and small series. Although these lesions have a purely extradural location of arteriovenous shunting and early venous drainage, they can be responsible for acute and progressive neurological symptoms similar to those caused by their dural-based intradural counterparts. With careful imaging recognition of the pathological anatomy, surgical and endovascular techniques can be used for the treatment of extradural AVMs affording effective and durable obliteration with stabilization or reversal of neurological symptoms. Venous drainage directly correlates the pathologic mechanisms of presentation. Specific attention must be paid intraoperatively to the epidural lake common to both variants so that recurrence is avoided.",
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AU - Piegras, David G.

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AB - Object. Although nontraumatic spinal arteriovenous malformations and fistulas (AVMs and AVFs) restricted to the epidural space are rare, they can lead to significant neurological morbidity. Careful diagnostic imaging is essential to their detection and the delineation of the pathological anatomy. Aggressive endovascular and open operative treatment can provide arrest and reversal of neurological deficits. Methods. The authors report on 6 cases of extradural AVMs/AVFs causing progressive myelopathy. Clinical findings, diagnostic evaluation, treatment, and outcome are discussed. Special consideration is given to the anatomy of the lesions and the operative techniques used to treat them. A review of the literature concerning extradural vascular malformations is also presented. Results. All 6 cases of extradural AVMs had an extradural fistulous location with intradural medullary venous drainage. These cases illustrate progressive myelopathy through cord venous congestion (hypertension) that can be caused by an extradural nidus or fistula. In 4 cases, a large epidural lake was identified on angiography. At surgery, the epidural lake was obliterated and medullary drainage interrupted. All patients had stabilization of their neurological deficits and successful obliteration of the AVM/AVF was obtained. Conclusions. Extradural AVMs and AVFs are a poorly described entity with published clinical experience limited to sporadic case reports and small series. Although these lesions have a purely extradural location of arteriovenous shunting and early venous drainage, they can be responsible for acute and progressive neurological symptoms similar to those caused by their dural-based intradural counterparts. With careful imaging recognition of the pathological anatomy, surgical and endovascular techniques can be used for the treatment of extradural AVMs affording effective and durable obliteration with stabilization or reversal of neurological symptoms. Venous drainage directly correlates the pathologic mechanisms of presentation. Specific attention must be paid intraoperatively to the epidural lake common to both variants so that recurrence is avoided.

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KW - Intraspinal angioma

KW - Spinal arteriovenous fistula

KW - Spinal arteriovenous malformation

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