Repeated surgical treatment and long-term outcome of a cat with vertebral vascular hamartoma.

A 30-month-old Maine Coon presented with progressive proprioceptive ataxia, paraparesis, thoracolumbar pain, and decreased appetite. An extradural mass was detected within the left side of the 13th thoracic vertebral canal that compressed the spinal cord on magnetic resonance (MR) and was considered to be mineralized on computed tomography (CT) images. The resected mass was diagnosed as a vertebral vascular hamartoma. Clinical signs improved, but recurrence was diagnosed by MR and CT imaging at 7 months after surgery. Repeated excisional surgery yielded the same diagnosis and the clinical signs abated. Fifteen months after the second surgery, there was apparent vertebral deformation, but there was no further change on CT images by 29 months.

[The application of hybrid operation suite in the management of cerebral and spinal vascular diseases and intracranial hypervascular tumors].

Objective: To evaluate the effect of hybrid operation suite in the treatment of cerebral and spinal vascular diseases and intracranial hypervascular tumors. Methods: A retrospective study was conducted on 132 patients with various cerebral and spinal vascular diseases and intracranial hypervascular tumors who were treated by hybrid surgery at Department of Neurosurgery, Huashan Hospital from October 2016 to December 2017.There were 70 male and 62 female patients with a mean age of 48.33 years (range: 14-78 years), including 64 cases of intracranial aneurysm (41 complicated aneurysm cases), 28 cases of brain arteriovenous malformation (BAVM), 12 cases of hypervascular tumor, 12 cases of dural arteriovenous fistula (DAVF), 6 cases of carotid artery stenosis, 5 cases of Moyamoya disease, 3 cases of intracranial aneurysm or BAVM combined with tumor, 1 case of scalp arteriovenous fistula and 1 case of critical brain trauma in which a foreign metal stick approached the basal vascular circuit.Abnormalities were found in 16 cases in intraoperative angiography. The clinical data of all patients was collected as a perspective cohort. The success rate of hybrid surgery, intra-operative and post-operative complications, morbidity, mortality, rate of infection, the length of hospital stay were all analyzed to illustrate the effect of hybrid operation mode to traditional surgical pattern. Results: For 64 cases with intracranial aneurysms, the immediate complete occlusion rate was 90.5%, with a mortality of 4.7% and a morbidity of 14.0%. For 28 cases of BAVM and 12 cases of DAVF, all patients achieved total obliteration and favorable social independent outcomes after hybrid surgery, with no complication.For 6 cases of carotid artery stenosis and 5 cases of Moyamoya, intra-operative confirmed good cerebral reperfusion without any new post-operative neurologic deficits. After tumor vessels embolization, 4 out of 12 cases of hypervascular tumor needed intra-operative blood transfusion, and all patients achieved total tumor resection in a single stage. Only one patient with medulla oblongata hemangioblastoma died 6 months after operation due to respiratory deficit related pneumonia. Compared to traditional surgeries, the hybrid operation pattern did not significantly increase the total infection rate, central nervous system infection rate, hospital stay days and post-operative hospital stay days (all P>0.05) while the in-patient cost increased mildly (119 332 yuan vs.98 215 yuan, t=2.38, P=0.02). Conclusions: The operations of complex cerebral and spinal vascular diseases and intracranial hypervascular tumors can be performed in hybrid operation suite safely.This surgical mode can ensure the quality of operation and promote the development of innovative and complicated surgical procedures.

Application of fluorescein sodium videoangiography in surgery for spinal arteriovenous malformation.

We present our recent experience with fluorescein sodium videoangiography (FLVA) in the intra-operative evaluation of a patient with conus medullaris arteriovenous malformation (AVM). To our knowledge this is the first report in the literature of use of FLVA in the surgery of spinal AVM. Intra-operative FLVA was done to identify an early filling vessel and to obliterate the site of fistulous connection. This was correlated and confirmed with simultaneous indocyanine green videoangiography (ICGVA). The conus and cauda equina roots could be appreciated and manipulated in relation to this fluorescence. Obliteration was confirmed with FLVA and correlated with ICGVA. There was no untoward reaction to the dye injection. We conclude that FLVA is a useful adjunct in the surgical treatment of conus medullaris AVMs since it is a real time, noninvasive, radiation-free, easily reproducible technique allowing surgical manipulation through the operating oculars with simultaneous visualization of surrounding critical structures.

[The history of surgery for brain and spinal cord vascular pathology at the Burdenko Neurosurgical Institute (to the 50th anniversary of foundation of the First Neurovascular Department)]. / Istoriya khirurgii sosudistoi patologii golovnogo i spinnogo mozga v Institute neirokhirurgii im. akad. N.N. Burdenko (k 50-letiyu osnovaniya pervogo neirososudistogo otdeleniya).

The Vascular Department of the Burdenko Neurosurgical Institute is one of the country's first dedicated departments engaged in treatment of patients with cerebrovascular diseases. The modern vascular service of the Institute is represented by several departments and groups: the Department of Microsurgical Treatment of Vascular Diseases, a group of Reconstructive Brachiocephalic Surgery, and the Department of Endovascular Surgery and Neurodiagnosis that is also engaged in intra-arterial chemotherapy and angiographic diagnosis. The neurovascular service of the Institute is a rightful leader of Russia in the number operations and their complexity: patients with the most serious and unusual pathologies are referred to the Institute from across the country. The achievements of the service are based on science and clinical practice that underlie progressive improvement in the diagnosis, surgical methodology, and recovery of neurovascular patients. On November 02, 2016, the Vascular Department of the Burdenko Neurosurgical Institute will celebrate the 50th anniversary of its foundation.

Idiopathic Cervical Hematomyelia in an Infant: Spinal Cord Injury without Radiographic Abnormality Caused by a Trivial Trauma? Case Report and Review of the Literature.

BACKGROUND: Spontaneous or idiopathic intramedullary bleeding is a very rare event in pediatric patients. This diagnosis requires an extended clinical, laboratory, and radiologic work-up to rule out all potential causes of hematomyelia. However, children may present with hematomyelia or spinal cord injury without radiographic abnormality even after a minor trauma. CASE DESCRIPTION: A 15-month-old girl presented with a 24-hour history of progressive neurologic deficits. A trivial trauma had occurred a few days before the clinical onset. Head computed tomography scan and craniospinal magnetic resonance imaging revealed an isolated hemorrhagic central medullary lesion extending from the obex to C3 level. No underlying causes of intramedullary bleeding were identified. In the absence of obvious vascular abnormalities, the patient underwent an urgent occipitocervical decompression with hematoma evacuation. Postoperatively, the patient's motor symptoms rapidly resolved, and she was discharged with cervical collar immobilization. CONCLUSIONS: We discuss the differential diagnosis of intramedullary bleeding in children, focusing on the diagnostic protocol and therapeutic options in this age group.

Craniovertebral fusion in an infant using struts of banked adult bone.

PURPOSE: The aim of this paper is to discuss the problems of craniocervical instability and craniocervical fusion in infancy. Despite the relative frequency of carniovertebral joint malformations, actual instability is quite rare in infancy. METHODS: An infant 8 months of age presented with tetraparesis and sleep apnea due to a complex malformation of her craniovertebral joint. An initial attempt at conservative treatment using a rigid neck collar failed, so the patient was surgically managed by the onlay placement of two autologous rib grafts. The rigid collar was maintained for 5 months. RESULTS: Both rib grafts progressively reabsorbed within a few months, while the clinical deficits recurred. Reoperation consisted of occipitocervical interposition of two robust struts of banked cadaveric adult fibula. This time, the skull appeared mature enough to allow immobilization by the halo system. Adequate occipitocervical fusion was eventually achieved, and the patient fully recovered. CONCLUSIONS: To the best of our knowledge, there is no other reported case of an infant undergoing craniovertebral fusion using cadaveric adult bone. When screw placement is not considered advisable to manage small infants, appropriate stability may be obtained using struts of robust cadaveric bone. A meticulous carpentry technique with graft interposition under compression and adequate postoperative immobilization remains mandatory.

Microsurgical resection of an intramedullary glomus arteriovenous malformation in the high cervical spinal cord: retrograde dissection techniques of the nidus located between spinal tracts.

BACKGROUND: Spinal intramedullary arteriovenous malformations (AVMs) fed by an anterior spinal artery are surgically challenging vascular lesions. METHOD: We herein presented microsurgical resection techniques for an intramedullary glomus AVM located in the lateral part of the high cervical spinal cord with an operative video. These techniques included (1) a lateral suboccipital approach via cervical hemilaminectomy in the lateral position; (2) retrograde dissection of the AVM located between the spinal tracts; (3) coagulation and division of multiple narrow sulcal branches of the anterior spinal artery. CONCLUSION: Patients who underwent these techniques achieved good outcomes with minimal bleeding and morbidity.

Suspected primary hematomyelia in 3 dogs.

Primary hematomyelia refers to hemorrhage occurring within the spinal cord without an identifiable etiology. Clinical signs, magnetic resonance imaging characteristics, and histopathological findings are described. Diagnosis was made through histological analysis and rule-outs for underlying factors. Following removal of the hematoma, neurologic deficits improved, although some residual deficits persisted.

Hématomyélie primaire suspectée chez 3 chiens. L'hématomyélie primaire fait référence à l'hémorragie qui se produit dans la moelle épinière sans une étiologie identifiable. Les signes cliniques, les caractéristiques de l'imagerie par résonance magnétique et les résultats de l'histopathologie sont décrits. Le diagnostic a été posé à l'aide d'une analyse histologique et de l'élimination des facteurs sous-jacents. Après l'enlèvement de l'hématome, le déficit neurologique s'est amélioré, même si des déficits résiduels ont persisté.(Traduit par Isabelle Vallières).

Microsurgical ligation of spinal arteriovenous fistulae: techniques.

Spinal dural arteriovenous fistula (dAVF) is an acquired abnormal arterial-to-venous connection within the spinal dura with a wide range of clinical presentations and natural history. Spinal dAVF occurs when a radicular artery makes a direct anomalous shunt with a radicular vein within the dura of the nerve root sleeve. Spinal dAVFs are the most common vascular malformation of the spine. The authors present a patient who presented with sudden temporary lower extremity weakness secondary to an L-1 spinal dAVF. The details of microsurgical techniques to disconnect the fistula are discussed in this video. The video can be found here: http://youtu.be/F9Kiffs3s6A.

Microsurgical obliteration of a thoracic spinal perimedullary arteriovenous fistula.

Spinal vascular lesions are rare and may be classified as a) dural arteriovenous fistulas (AVFs), b) arteriovenous malformations, or c) perimedullary AVFs. In this narrated video illustration, we present the case of a 71-year-old woman who presented with progressive bilateral lower extremity weakness and urinary retention who was diagnosed with a thoracic spinal perimedullary arteriovenous fistula. The diagnostic studies included a thoracic MRI and spinal angiogram. A multilevel thoracic laminoplasty was performed for microsurgical obliteration of the AVF. The techniques of intraoperative angiography, thoracic laminoplasty and microsurgical obliteration and resection of the AVF are reviewed. The video can be found here: http://youtu.be/5vVp3oq5sLg.

High cervical arteriovenous fistulas fed by dural and spinal arteries and draining into a single medullary vein: report of 3 cases.

OBJECT: The authors previously reported a case of complex arteriovenous fistula (AVF) at C-1 with multiple dural and spinal feeders that were linked with a common medullary venous channel. The purpose of the present study was to collect similar cases and analyze their angioarchitecture to gain a better understanding of this malformation. METHODS: Three such cases, affecting 2 males and 1 female in their 60s who had presented with hematomyelia (2) or progressive myelopathy (1), were treated surgically, and the operative findings from all 3 cases were compared using digital subtraction angiography (DSA) to determine the angioarchitecture. RESULTS: The C-1 and C-2 radicular arteries and anterior and posterior spinal arteries supplied feeders to a single medullary draining vein in various combinations and via various routes. The drainage veins ran along the affected ventral nerve roots and lay ventral to the spinal cord. The sites of shunting to the vein were multiple: dural, along the ventral nerve root in the subarachnoid space, and on the spinal cord, showing a vascular structure typical of dural AVF, that is, a direct arteriovenous shunt near the spinal root sleeve fed by one or more dural arteries and ending in a single draining vein, except for intradural shunts fed by feeders from the spinal arteries. In 2 cases with hemorrhagic onset the drainer flowed rostrally, and in 1 case associated with congestive myelopathy the drainer flowed both rostrally and caudally. Preoperative determination of the shunt sites and feeding arteries was difficult because of complex recruitment of the feeders and multiple shunt sites. The angioarchitecture in these cases was clarified postoperatively by meticulous comparison of the DSA images and operative video. Direct surgical intervention led to a favorable outcome in all 3 cases. CONCLUSIONS: A high cervical complex AVF has unique angioarchitectural characteristics different from those seen in the other spinal regions.

Spinal dural arteriovenous shunt presenting with intramedullary hemorrhage: case report.

The authors report on a 49-year-old man with a thoracic spinal dural arteriovenous shunt (dAVS) in which rupture of a varix caused intramedullary hemorrhage. In the literature, patients with a thoracic dAVS predominantly present with congestive myelopathy; however, the patient featured in this report presented without increased deep tendon reflexes or muscle weakness, but instead with intermittent stabbing chest pain and paresthesia. Magnetic resonance images and angiograms demonstrated tortuous enlargement and the formation of a varix-like structure of the draining veins, features compatible with those of high-flow angiopathy. Recognition of this phenomenon is important in thoracic dAVS because intramedullary hemorrhage dramatically degrades outcome. A high index of clinical suspicion can prevent a similar case of thoracic dAVS from progressing to intramedullary hemorrhage.

Surgical treatment of spinal vascular malformations performed using intraoperative indocyanine green videoangiography.

This study aims to evaluate the benefits of intraoperative indocyanine green (ICG) videoangiography and associated surgical outcomes of patients with spinal vascular malformations. ICG videoangiography was used during 24 surgical interventions to treat spinal vascular malformations at the Beijing Tiantan Hospital from August 2009 to May 2011. The vascular malformations were removed or the fistulae were occluded with the assistance of ICG videoangiography. The completeness of fistula clipping or nidus extirpation and each patient's neurological status were evaluated. Among these 24 patients, there were seven with spinal dural arteriovenous fistulae, five glomus arteriovenous malformations, one juvenile arteriovenous malformation, nine perimedullary arteriovenous fistulae, and two perimedullary arteriovenous fistulae in combination with perimedullary arteriovenous malformations. Intraoperative ICG videoangiography confirmed the definite clipping of the fistulous points and complete removal of intramedullary arteriovenous malformations in all but one patient. All patients had satisfactory preservation of spinal cord blood supply and venous return. No adverse effects or complications related to ICG videoangiography occurred. Three patients were lost to follow up; 21 patients were followed clinically with a mean follow up of 7.5 months. The neurological deficits completely resolved in six patients, improved significantly in 10, remained stable in two, and were aggravated in three patients. Our experience shows that intraoperative ICG videoangiography offers useful information on the pathological and physiological vascular anatomy encountered during surgery for spinal vascular malformations.

Clinical features and treatment outcomes of the spinal arteriovenous fistulas and malformation: clinical article.

OBJECT: Spinal vascular diseases, such as spinal dural arteriovenous fistulas (DAVFs), perimedullary arteriovenous fistulas (AVFs), and spinal arteriovenous malformations (AVMs), are very rare. The authors analyzed the features and treatment outcomes of these conditions. METHODS: Data from 64 patients were retrospectively reviewed. There were 33 spinal DAVFs (1 patient had 2 lesions), 20 perimedullary AVFs, and 12 spinal AVMs. Clinical features, radiological findings, treatment results, and clinical outcomes were evaluated according to the diseases, subtypes, and treatment modalities. The median duration of follow-up was 20, 42, and 56 months for spinal DAVFs, perimedullary AVFs, and spinal AVMs, respectively. RESULTS: Spinal DAVFs showed faster progression of symptoms (median 5, 12, and 36 months for spinal DAVFs, perimedullary AVFs, and spinal AVMs, respectively) and worse neurological status at diagnosis (poor neurological status in 56%, 65%, and 33%, respectively). On MRI, signal voids were demonstrated in all except 1 spinal DAVF. At the last follow-up, 94% of spinal DAVFs, 68% of perimedullary AVFs, and 50% of spinal AVMs were completely obliterated. Favorable clinical outcomes were achieved in 91%, 95%, and 58%, respectively. In detail, the majority (78%) of spinal DAVFs were embolized, resulting in complete obliteration in 92% and favorable clinical outcomes in 92%. Most Type IVa and IVb perimedullary AVFs were surgically treated (71% and 88%), with complete obliterations of 86% and 71%, and favorable clinical outcomes in 100% and 86%, respectively. All Type IVc lesions were embolized with a low cure rate of 40%; however, clinical outcomes were satisfactory. Spinal AVMs were generally embolized (67%), and only glomus-type lesions attained a satisfactory cure rate (80%) and clinical outcome (100%). CONCLUSIONS: Embolization produced satisfactory outcomes in spinal DAVFs and glomus-type spinal AVMs. Surgery is advantageous in Type IVa and IVb perimedullary AVFs. Palliative embolization can be effective in Type IVc perimedullary AVFs and juvenile spinal AVMs.

Rotational angiography for diagnosis and surgical planning in the management of spinal vascular lesions.

OBJECT: The management of spinal vascular malformations has undergone significant evolution with the advent of advanced endovascular and angiographic technology. Three-dimensional rotational spinal angiography is an advanced tool that allows the surgeon to gain a better appreciation of the anatomy of these spinal vascular lesions and their relation to surrounding structures. This article describes the use of rotational angiography and 3D reconstructions in the diagnosis and management of spinal vascular malformations. METHODS: The authors present representative cases involving surgical treatment planning for spinal vascular malformations with focus on the utility and technique of rotational spinal angiography. They report the use of rotational spinal angiography for a heterogeneous collection of vascular pathological conditions. RESULTS: Eight patients underwent rotational spinal angiography in addition to digital subtraction angiography (DSA) for the diagnosis and characterization of various spinal vascular lesions. Postprocessed images were used to characterize the lesion in relation to surrounding bone and to enhance the surgeon's ability to precisely localize and obliterate the abnormality. The reconstructions provided superior anatomical detail compared with traditional DSA. No associated complications from the rotational angiography were noted, and there was no statistically significant difference in the amount of radiation exposure to patients undergoing rotational angiography relative to traditional angiography. CONCLUSIONS: The use of rotational spinal angiography provides a rapid and powerful diagnostic tool, superior to conventional DSA in the diagnosis and preoperative planning of a variety of spinal vascular pathology. A more detailed understanding of the anatomy of such lesions provided by this technique may improve the safety of the surgical approach.