Sections

Arteriovenous Malformations and Fistulas (AVM/AVF) of the Spinal Cord

Sections Arteriovenous Malformations and Fistulas (AVM/AVF) of the Spinal Cord
Overview
Workup
Treatment
Guidelines
Media Gallery
References

Workup

Imaging Studies

Imaging protocols are less standardized for the spine and spinal cord than for the brain. The most important difficulties for optimization of sequences are due to the many interfaces that exist in this region, such as bone–cerebrospinal fluid (CSF) and spinal cord–CSF, the proximity of the lungs, and the mobile character and size of the spinal cord and its adjacent structures.^[13]

Plain radiography is not usually helpful for diagnosis. Computed tomography (CT) scanning may reveal dilated vessels in the thecal sac, but findings are usually normal. If a patient presents with symptoms of subarachnoid hemorrhage, CT scanning demonstrates blood in the spinal fluid.

Myelography findings, with or without CT, show dilated vessels in the intradural space. This imaging modality is very sensitive and shows these abnormalities in detail. This is an invasive procedure that requires injection of a contrast agent into the thecal sac. Postprocedural headache is not uncommon.

On magnetic resonance imaging (MRI), soft tissue and neural elements are visualized in detail. Dilated intradural vessels can be seen as flow voids or can be seen filling with contrast. Edema or hemorrhage in the spinal cord parenchyma can be assessed. The exact fistula site cannot be localized. Sequences indispensable to a basic MRI clinical protocol for any spine or spinal cord examination are fast spin echo (FSE) T2 and spin echo (SE) T1. All spinal investigations should have sequences in both sagittal and axial planes to identify exact location and to attain better visualization of lesions. Advanced sequences may be employed as well.^[13]

Magnetic resonance angiography (MRA) and CT angiography (CTA) are noninvasive modalities that can be used to identify abnormal vessels. However, resolution of these modalities is not yet optimal. The pathology must be confirmed by spinal angiography.^[10]

Spinal digital subtraction angiography (DSA) is the gold standard for the diagnosis of spinal AVM and is an indispensable tool for treatment planning.^[8]

Arteriography is the criterion standard for visualizing AVMs. This dynamic study allows visualization of the pathology in real time, enabling assessment of high-flow versus low-flow AVMs. In addition, the location of the fistula can be visualized. Arteriography is an invasive procedure that may cause morbidity such as spinal cord ischemia, cerebrovascular accident, or vascular dissection. Comparison of a prospective series of consecutive right transradial diagnostic cerebral arteriograms versus a procedural staging system revealed that neurointerventionalists can achieve high success rates and low crossover rates after performing this procedure.^[14]

Vascular malformations of the spine frequently have distinguishing characteristics on imaging that are imperative for the radiologist to recognize to provide proper guidance for diagnosis and treatment.^[2] Advances in neurovascular imaging, along with increased utilization of these advances, have resulted in more frequent identification of these lesions.^[1] Often, radiologists are the first to guide the clinician toward an adequate diagnosis.^[10] Clinical challenges that neuroradiologists may face include "when" and "where" concerning the use of each technique and for which pathology or clinical scenario each technique is most useful.^[13]

Typically, spinal MRI is ordered as a first-line screening method to detect spinal vascular malformations. If a spinal vascular malformation is still suspected, digital subtraction angiography (DSA) must be performed to display the very small vessels of the spinal cord. Because of complications involved with DSA, MRA or CTA can be used to determine the spinal cord level of the feeding artery, thus limiting the amount of time needed before the DSA procedure is performed.^[15]

No laboratory studies are useful for the diagnosis of spinal cord vascular malformations. However, if the patient presents with symptoms of subarachnoid hemorrhage, lumbar puncture or computed tomography (CT) scan reveals blood in the spinal fluid.

Treatment & Management

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Feghali J, Huang J. Updates in arteriovenous malformation management: the post-ARUBA era. Stroke Vasc Neurol. 2020. 5 (1):34-9. [QxMD MEDLINE Link].
Baharvahdat H, Ooi YC, Kim WJ, et al. Updates in the management of cranial dural arteriovenous fistula. Stroke Vasc Neurol. 2020. 5 (1):50-8. [QxMD MEDLINE Link].
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Ehresman J, Catapano JS, Baranoski JF, et al. Treatment of spinal arteriovenous malformation and fistula. Neurosurg Clin N Am. 2022 Apr. 33 (2):193-206. [QxMD MEDLINE Link].
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Media Gallery

Spinal malformation. This is a sagittal T2-weighted MRI of the thoracic spine of a 68-year-old woman with a 9-month history of back pain and sensory loss, progressing to the point of loss of bowel and bladder function along with a sudden onset of paraparesis. Note the thoracolumbar junction with an edematous spinal cord and dilated serpiginous intradural venous plexus.
Spinal malformation. This is an axial T2-weighted MRI of the thoracic spine of a 68-year-old woman with a 9-month history of back pain and sensory loss, progressing to the point of loss of bowel and bladder function along with a sudden onset of paraparesis. Note the lumbar spine with an edematous spinal cord and dilated intradural venous plexus.

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Author

Glenn A Gonzalez, MD Post-Doctoral Research Fellow, Department of Neurosurgery, Sidney Kimmel Medical College of Thomas Jefferson University

Disclosure: Nothing to disclose.

Coauthor(s)

Tristan Blase Fried, MD Resident Physician, Department of Orthopedic Surgery, Thomas Jefferson Hospital

Disclosure: Nothing to disclose.

Corey E Cheresnick Jefferson Medical College of Thomas Jefferson University

Disclosure: Nothing to disclose.

George M Ghobrial, MD Resident Physician, Department of Neurological Surgery, Thomas Jefferson University Hospital

Disclosure: Nothing to disclose.

Aaron S Dumont, MD Charles B Wilson Professor and Chairman, Department of Neurological Surgery, Tulane University School of Medicine

Aaron S Dumont, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, North American Skull Base Society, Society of NeuroInterventional Surgery, Neurocritical Care Society

Disclosure: Nothing to disclose.

James W Pritchett, MD Chief of Orthopedic Surgery, Swedish Orthopedic Institute; Active Staff, Swedish Medical Center

James W Pritchett, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, Washington State Medical Association, Association of Bone and Joint Surgeons

Disclosure: Nothing to disclose.

James S Harrop, MD Associate Professor, Departments of Neurological and Orthopedic Surgery, Jefferson Medical College of Thomas Jefferson University

James S Harrop, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Spinal Injury Association, Cervical Spine Research Society, Congress of Neurological Surgeons, North American Spine Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Depuy spine consulant, Asterias, Bioventus, Tejin serve on advisory boards<br/>Received research grant from: DOD, PICORI<br/>Received income in an amount equal to or greater than $250 from: Stryker honorarium.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons, International Parkinson and Movement Disorder Society, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting; Received Consulting Fee from ClearPoint Neuro.

Additional Contributors

Paul L Penar, MD, FACS Professor, Department of Surgery, Division of Neurosurgery, Director, Functional Neurosurgery and Radiosurgery Programs, University of Vermont College of Medicine

Paul L Penar, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, World Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Pascal M Jabbour, MD Cerebrovascular Fellowship, Department of Neurosurgery, Thomas Jefferson University Hospital

Pascal M Jabbour, MD is a member of the following medical societies: Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Jennifer Malone, RN Department of Neurosurgery, Jefferson Medical College

Disclosure: Nothing to disclose.

Gregory J Przybylski, MD Professor of Neurological Surgery, Seton Hall University, School of Graduate Medical Education; Director of Neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center

Disclosure: Nothing to disclose.

Sections Arteriovenous Malformations and Fistulas (AVM/AVF) of the Spinal Cord
Overview
Workup
Treatment
Guidelines
Media Gallery
References

Arteriovenous Malformations and Fistulas (AVM/AVF) of the Spinal Cord Workup

Imaging Studies

References

Tables

Contributor Information and Disclosures

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