High diagnostic performance of time-resolved MR angiography in spinal arteriovenous shunts.

BACKGROUND AND PURPOSE: In comparison with the limited efficacy of conventional MR imaging and the invasiveness of catheter-based digital subtraction angiography (DSA), time-resolved MR angiography (TR-MRA) has been proposed as a promising examination for early diagnosis of spinal arteriovenous shunts (SAVSs). This paper aims to investigate the diagnostic performance of TR-MRA with scan parameters optimized for SAVSs evaluation in a large number of patients. METHODS: One hundred patients with suspected SAVSs were enrolled. Each patient underwent preoperative TR-MRA with optimized scan parameters followed by DSA. The presence or absence of SAVS, the types and the angioarchitecture of SAVSs in the TR-MRA images were diagnostically analyzed. RESULTS: Among the final 97 patients, 80 cases (82.5 %) were diagnosed and classified by TR-MRA as spinal cord arteriovenous shunts (SCAVSs; n = 22), spinal dural arteriovenous shunts (SDAVSs; n = 48), and spinal extradural arteriovenous shunts (SEDAVSs; n = 10). The agreement for classifying SAVSs between TR-MRA and DSA was excellent (κ = 0.91). The sensitivity, specificity, PPV, NPV, and accuracy of TR-MRA for the diagnosis of SAVSs were 100 % (95 % CI, 94.3-100.0 %), 76.5 % (95 % CI, 49.8-92.2 %), 95.2 % (95 % CI, 87.6-98.5 %), 100 % (95 % CI, 71.7-100.0 %), and 95.9 % (95 % CI, 89.9-98.4 %). The accuracy rates of TR-MRA for the detection of feeding arteries were 75.9 %, 91.7 %, and 80.0 % for SCAVSs, SDAVSs, and SEDAVSs respectively. CONCLUSION: Time-resolved MR angiography showed excellent diagnostic performance for SAVSs screening. Additionally, this method can classify SAVSs and identify feeding arteries in SDAVSs with high diagnostic accuracy.

Potential biomarkers of spinal dural arteriovenous fistula: C4BPA and C1QA.

BACKGROUND AND PURPOSE: A major challenge in spinal dural arteriovenous fistula (SDAVF) is timely diagnosis, but no specific predictive biomarkers are known. METHODS: In the discovery cohort (case, n = 8 vs. control, n = 8), we used cerebrospinal fluid (CSF) and paired plasma samples to identify differentially expressed proteins by label-free quantitative proteomics. Further bioinformatics enrichment analyses were performed to screen target proteins. Finally, it was validated by ELISA in two of the new cohorts (case, n = 17 vs. control, n = 9), and univariate analysis, simple linear regression, and receiver operator characteristic (ROC) curve analysis were performed to evaluate the diagnostic potential. RESULTS: In the discovery cohort, the most overexpressed proteins were APOB and C4BPA in CSF samples of patients. The GO/KEGG enrichment analysis indicated that the upregulated proteins were mainly involved in the acute inflammatory response and complement activation. Hub-gene analysis revealed that APP might be the key protein in the molecular interaction network. In the validation cohort, C4BPA and C1QA were significantly overexpressed in the CSF of patients, averaging 3046.9 ng/ml and 2167.2 ng/ml, respectively. Simple linear regression demonstrated that levels of C1QA and C4 were positively correlated with total protein in CSF (R2 = 0.8021, p = 0.0005; R2 = 0.7447, p = 0.0013). The areas under the ROC curves of C4BPA and C1QA were 0.86 and 1.00, respectively. CONCLUSIONS: This study was the first to identify C4BPA and C1QA as potential biomarkers for the diagnosis of SDAVF and revealed that complement pathway activation might be one of the molecular mechanisms for venous hypertension myelopathy.

Vertebral Artery Transposition and Dural Ring Reconstruction: A New Treatment Modality for Cervical Spinal Cord Compression Resulting From Aberrant Vertebral Arteries.

BACKGROUND: Two of three patients who were consecutively treated within the past 7 years using traditional methods in our center presented with recurrence and even aggravation during follow-up. Therefore, a new approach was developed to treat a recent patient to provide for complete decompression of the spinal cord. OBJECTIVE: To illustrate a new treatment modality for patients with cervical spinal cord compression resulting from aberrant vertebral arteries. METHODS: The aberrant vertebral arteries were freed after substantial dissection of their dural rings. The compression was released after moving the aberrant vertebral arteries, which were sutured to the lateral mass to the extradural space. New dural rings above the atlas were created to allow the vertebral artery to enter the dura mater into a wider subdural space. RESULTS: The patient experienced full relief from her initial complaints except for mild numbness of the bilateral lower extremities immediately after surgery. Postoperative imaging studies indicated successful transposition of bilateral aberrant vertebral arteries and significant decompression of the spinal cord. Her symptoms did not recur over a 6-month follow-up period. Imaging studies at the 6-month follow-up showed stable vertebral artery transposition and spinal cord decompression. CONCLUSION: A patient with cervical spinal cord compression resulting from aberrant vertebral arteries was successfully treated by our new technique, which includes vertebral artery transposition, fixation, and dural ring reconstruction. Our approach could be an alternative for durable spinal cord decompression in such patients.

Natural History and Clinical Outcomes of Paravertebral Arteriovenous Shunts.

BACKGROUND AND PURPOSE: Paravertebral arteriovenous shunts (PVAVSs) are rare. Whether the intradural venous system is involved in drainage may lead to differences in clinical characteristics through specific pathophysiological mechanisms. This study aims to comprehensively evaluate the natural history and clinical outcomes of PVAVSs with or without intradural drainage. METHODS: Sixty-four consecutive patients with PVAVSs from 2 institutes were retrospectively reviewed. Lesions were classified as type A (n=28) if the intradural veins were involved in drainage; otherwise, they were classified as type B (n=36). The clinical course from initial presentation to the last follow-up was analyzed. RESULTS: The patients with type A shunts were older at presentation (52.5 versus 35.5 years, P<0.0001) and more likely to have lower spinal segments affected than patients with type B PVAVSs (67.8% versus 13.9%, P=0.00006). After presentation, the deterioration rates related to gait and sphincter dysfunction were significantly higher in patients with type A than type B shunts (gait dysfunction: 71.8%/y versus 17.0%/y, P=0.0006; sphincter dysfunction: 63.7%/y versus 11.3%/y, P=0.0002). According to the angiogram at the end of the latest treatment, 79% of type A and 75% of type B PVAVSs were completely obliterated. If the lesions were partially obliterated, a significantly higher clinical deterioration rate was observed in patients with type A shunts than those with type B shunts (69.9%/y versus 3.2%/y, P=0.0253). CONCLUSIONS: Type A PVAVSs feature rapid progressive neurological deficits; therefore, early clinical intervention is necessary. For complex lesions that cannot be completely obliterated, surgical disconnection of all refluxed radicular veins is suggested.

Current Knowledge of and Perspectives about the Pathogenesis of Blood Blister-like Aneurysms of the Internal Carotid Artery: A Review of the Literature.

Blood blister-like aneurysms (BBAs) are rare and usually appear at nonbranching sites in the supraclinoid portion of the internal carotid artery (ICA). Because it is difficult to obtain histological specimens of the aneurysm wall and because experimental models are challenging to establish, the pathogenesis of BBAs remains uncertain. In this paper, we reviewed the diagnostic, radiological, and pathophysiological characteristics of patients with BBAs. We also summarized the existing evidence and potential mechanisms related to the causes of BBAs. Current evidence indicates that atherosclerosis and dissection are the main prerequisites for the formation of BBAs. Hemodynamics may play a role in the process of BBA formation due to the unique vascular anatomy of the supraclinoid ICA. Further research on histopathology and hemodynamics is warranted in this field.