The efficacy and deficiency of contemporary treatment for spinal cord arteriovenous shunts.

Contemporary treatments for spinal cord arteriovenous shunts are only based on clinicians' treatment experiences and expertise due to its rarity. We reviewed the clinical course of the largest multicentred cohort to evaluate the efficacy and deficiency of contemporary interventional treatments for spinal cord arteriovenous shunts. The clinical features, treatment results and clinical outcomes of 463 patients with spinal cord arteriovenous shunts were retrospectively assessed. The main outcome was the neurological deterioration that was evaluated based on the modified Aminoff and Logue scale. According to post-treatment digital subtraction angiography, complete obliteration was defined as disappearance of the intradural lesion, whereas partial obliteration was defined as any residual intradural lesion remaining visible and was further categorized as shunt-reduction obliteration (the nidus or shunt points were reduced) or palliative obliteration (only obliterated aneurysms or feeders). Cure rate was 40.6% for the whole cohort, 58.5% after microsurgery, and 26.4% after embolization. The curative resection was associated with non-metameric lesions, lesions with a maximum diameter <3 cm and lesions without anterior sulcal artery supply. The curative embolization was associated with fistula-type lesions, non-metameric lesions, and main drainage diameter <1.5 mm. The permanent treatment-related neurological deficits rate was 11.2% for the whole cohort, 16.1% after microsurgery, and 5.6% after embolization. The pretreatment clinical deterioration rate was 32.5%/year, which decreased to 9.3%/year after clinical interventions. Following partial treatment, the long-term acute and gradual deterioration rates were 5.3%/year and 3.6%/year, respectively. The acute deteriorations were associated with metameric lesions, craniocervical lesions, lesions with a maximum diameter ≥2 cm and residual aneurysm. Residual aneurysm was the only predictor of acute deterioration for non-metameric spinal cord arteriovenous shunts. The gradual deteriorations were associated with palliative obliteration, absence of pretreatment acute deterioration and intact main drainage. Although clinical risks of spinal cord arteriovenous shunts were reduced following clinical interventions, contemporary treatments for spinal cord arteriovenous shunt remains associated with considerable risks and incomplete efficacy. Individualized treatment plans should be adopted according to the angio-architectural features and major clinical risks of specific lesions. There is a higher opportunity for complete obliteration for lesions with simple angio-architecture. However, for most of spinal cord arteriovenous shunts with complex vascular anatomy, partial treatment is the only choice. For these patients, palliative obliteration targeting the aneurysms is recommended for reducing haemorrhagic risk, whereas shunt-reduction obliteration is necessary for non-haemorrhagic myelopathy. Contemporary treatment is ineffective in reducing haemorrhagic risk of incurable metameric spinal cord arteriovenous shunts.

Natural history of spinal cord arteriovenous shunts: an observational study.

The natural history of intradural spinal cord arteriovenous shunts is unknown. We performed an observational study in a consecutive patient cohort with symptomatic intradural spinal cord arteriovenous shunts who were admitted to three institutes to investigate the clinical course of this complex disease, which would provide valuable evidence to inform clinical decision-making. The clinical course of patients with symptomatic intradural spinal cord arteriovenous shunts from initial presentation to occurrence of clinical deterioration, initiation of treatment, or last follow-up was analysed. Patients with at least 1 month of observation were included in this study. Clinical onset and deterioration patterns were divided into acute and gradual. Annual and cumulative rates of clinical deterioration as well as their risk factors were analysed using Kaplan-Meier life table analysis and Cox proportional hazards model. To assess risks and benefits of treatment, post-treatment clinical courses were further assessed. Four hundred and sixty-six patients with a mean observational period of 36.9 ± 58.8 months were included; 56.7% of patients presented with acute onset, of whom 77.3% experienced spontaneous recovery. Age of onset older than 28 years, initial modified Aminoff and Logue scale of >3, mid-thoracic lesions and non-ventral lesions were independent predictors of failure for spontaneous recovery. The annual risk of general, acute and gradual clinical deterioration after onset was 30.7%, 9.9% and 17.7%, respectively. Risk of deterioration was highest in the early period after initial onset. Acute onset was the only independent risk factor [hazard ratio 1.957 (95% confidence interval, CI 1.324-2.894); P = 0.0008] of acute deterioration and gradual onset was the strongest predictor [hazard ratio 2.350 (95% CI 1.711-3.229); P < 0.0001] of the gradual deterioration among all the stratifying factors. After invasive treatment, complete obliteration was achieved in 37.9% of patients (138 of 364) and improved or stable clinical status was noted in 80.8% of patients. Forty-two patients (11.5%) experienced permanent complications. Overall post-treatment deterioration rate was 8.4%/year, and 5.3%/year if permanent complications were excluded. The natural history of symptomatic spinal cord arteriovenous shunts is poor, especially in the early period after onset, and early intervention is thus recommended. Initial onset pattern significantly affects the natural history of the lesion, which prompts a differentiated treatment strategy.

[Feasibility and efficiency of embolization of spinal dural arteriovenous fistula].

OBJECTIVE: To evaluate the feasibility and efficiency of embolization of spinal dural arteriovenous fistula (SDAVF). METHODS: From December 2010 to May 2012, there were 104 cases of SDAVF were treated, and 26 cases were selected to be treated with embolization. The inclusion criteria was as follows: (1) No anterior or posterior spinal artery originated from the fistula segment; (2) The segmental artery can be catheterized with guiding or micro catheter; (3) High flow in fistula; (4) Patient's situation was not suitable for surgery or general anesthesia. Among 26 cases, there were 22 male and 4 female patients, the average age was 55.9 years (ranged from 34 to 81 years). The locations of SDAVF were 10 cases in thoracic, 9 in lumbar and 7 in sacral segment. The main symptoms were progressive numbness and weakness in both lower extremities, most cases accompanied with difficulties in urination and defecation. The average history was 17.1 months (from 1 to 156 months). ONYX-18 liquid embolic agent or Glubran-2 surgical glue were used as embolic material. The patients not cured with embolization were treated with surgery in the following 1 - 2 weeks. Follow-up evaluation was done with MRI after 3 months and DSA after 6 months, besides physical examination. RESULTS: Fifteen from 26 cases achieved immediate angiographic cure results: 14 in 20 cases which embolized with ONYX-18; only 1 in 6 cases with Glubran-2. Three in 10 cases of thoracic SDAVF and 12 in 16 cases of lumbar/sacral SDAVF were cured with embolization. Partially embolized cases were treated with surgical obliteration of drainage veins within 2 weeks. Cured patients experienced immediate improvement after embolization and kept getting better in the follow-up. All the patients had MRI follow-up after 3 months and DSA follow-up after 6 months. In 6 month's follow-up, MRI showed the edema and flow void signal in the spinal cord disappeared. DSA showed no fistula recurrence or remnant. There was no deterioration case in all of the embolized cases. CONCLUSIONS: Particular SDAVF is suitable for embolization with ONYX-18. Most lesions located in lumbar and sacral segment are good indications for embolization.

Filum Terminale Arteriovenous Fistulas with Multiple Shunt Points: A Report of Two Exceptional Cases.

BACKGROUND: Filum terminale arteriovenous fistula (FTAVF) with multiple shunt points has not been reported in the literature. In previous studies, the angioarchitecture of FTAVFs was always featured with only one single shunt point, and such a uniformity had established the preconceived and conventional understanding of FTAVFs for clinicians. CASE DESCRIPTION: The authors describe 2 exceptional cases of FTAVFs with multiple shunt points confirmed by open surgery, which means that the above understanding may lead to misdiagnosis and incomplete treatment in future. The surgery of both cases was performed in a hybrid operating room, and all of shunt points were obliterated with the help of intraoperative digital subtraction angiography. CONCLUSIONS: The exceptional finding of these 2 cases is a renewal of the conventional understanding of FTAVFs, not only for the angioarchitecture of the lesions but also for the treatment strategy.

Spontaneous Spinal Epidural Hematoma: A Study of 55 Cases Focused on the Etiology and Treatment Strategy.

BACKGROUND: Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic emergency of the spinal cord. Its cause and treatment strategy remain controversial. This study aimed to evaluate a significant cause of SSEH and to discuss the treatment strategy according to the clinical outcomes of patients in 2 institutions. METHODS: Fifty-five cases of SSEH treated at our institutions between February 2002 and February 2016 were retrospectively analyzed. RESULTS: The mean age of the first SSEH onset was 31.8 years. The follow-up rate was 72.7%, with 28 patients (70%) showing satisfactory clinical outcomes. Forty patients received preoperative spinal digital subtraction angiography. Spinal epidural (extradural) arteriovenous fistula was detected in 6 patients (15%), 5 of whom showed 1 type of special slow-flow shunt. Nineteen patients (34.5%) suffered from multiple episodes until they underwent invasive treatments or last follow-up. Rebleeding was confirmed in 8 patients. None of the patients had a subsequent episode or rebleeding after invasive treatment. The risk factors for poor clinical outcome included advanced age at initial onset (P = 0.020), a short progression interval (P = 0.030), no symptom relief after admission (P = 0.011), hypesthesia (P = 0.017), complete spinal cord injury (P = 0.001), and hematoma below the T4 level (P = 0.014). CONCLUSIONS: Spinal epidural (extradural) arteriovenous fistula is a significant cause of SSEH. Standard spinal digital subtraction angiography is necessary for patients with SSEH. Conservative treatment could not prevent occurrence of multiple episodes or rebleeding in patients. Microsurgery should be recommended as the preferred treatment strategy for SSEH. Endovascular embolization is also recommended if applicable.

A trapping-evacuation technique for giant carotid-ophthalmic segment aneurysm clipping in a hybrid operating theater.

It is essential to collapse giant carotid-ophthalmic (OA) segment aneurysms for successful microsurgical clipping. We present a trapping-evacuation technique utilising hybrid operating theater capabilities to soften OA aneurysms. The patients were prepared for both microsurgical and endovascular procedures. After the majority of the aneurysm was exposed, a balloon was placed at the orifice of the aneurysm to fully block the blood flow. When the balloon was inflated, blood was evacuated from the aneurysm sac to eliminate the space occupying effect. Subsequently, the aneurysm neck was clearly exposed which greatly facilitated clip placement. A control angiogram was obtained prior to closing the wound to ensure complete aneurysm obliteration. After the establishment of a hybrid operating theater in our hospital, two aneurysms were successfully clipped using this technique. Although postoperative complications occurred in both patients, none of the events were related to the endovascular procedure or the trapping-evacuation technique. As a well-organized procedure designed for use in a hybrid operating theater, the current trapping-evacuation technique is an option for the surgical clipping of giant OA aneurysms.