Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial.

BACKGROUND AND PURPOSE: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS: Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS: Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.

First-Pass Contrast-Enhanced MRA for Pretherapeutic Diagnosis of Spinal Epidural Arteriovenous Fistulas with Intradural Venous Reflux.

BACKGROUND AND PURPOSE: Spinal epidural AVFs are rare spinal vascular malformations. When there is associated intradural venous reflux, they may mimic the more common spinal dural AVFs. Correct diagnosis and localization before conventional angiography is beneficial to facilitate treatment. We hypothesize that first-pass contrast-enhanced MRA can diagnose and localize spinal epidural AVFs with intradural venous reflux and distinguish them from other spinal AVFs. MATERIALS AND METHODS: Forty-two consecutive patients with a clinical and/or radiologic suspicion of spinal AVF underwent MR imaging, first-pass contrast-enhanced MRA, and DSA at a single institute (2000-2015). MR imaging/MRA and DSA studies were reviewed by 2 independent blinded observers. DSA was used as the reference standard. RESULTS: On MRA, all 7 spinal epidural AVFs with intradural venous reflux were correctly diagnosed and localized with no interobserver disagreement. The key diagnostic feature was arterialized filling of an epidural venous pouch with a refluxing radicular vein arising from the arterialized epidural venous system. CONCLUSIONS: First-pass contrast-enhanced MRA is a reliable and useful technique for the initial diagnosis and localization of spinal epidural AVFs with intradural venous reflux and can distinguish these lesions from other spinal AVFs.

Comparison of Sagittal FSE T2, STIR, and T1-Weighted Phase-Sensitive Inversion Recovery in the Detection of Spinal Cord Lesions in MS at 3T.

BACKGROUND AND PURPOSE: Determining the diagnostic accuracy of different MR sequences is essential to design MR imaging protocols. The purpose of the study was to compare 3T sagittal FSE T2, STIR, and T1-weighted phase-sensitive inversion recovery in the detection of spinal cord lesions in patients with suspected or definite MS. MATERIALS AND METHODS: We performed a retrospective analysis of 38 patients with suspected or definite MS. Involvement of the cervical and thoracic cord segments was recorded on sagittal FSE T2, STIR, and T1-weighted phase-sensitive inversion recovery sequences independently by 2 readers. A consensus criterion standard read was performed with all sequences available. Sensitivity, specificity, and interobserver agreement were calculated for each sequence. RESULTS: In the cervical cord, the sensitivity of T1-weighted phase-sensitive inversion recovery (96.2%) and STIR (89.6%) was significantly higher (P < .05) than that of FSE T2 (50.9%), but no significant difference was found between T1-weighted phase-sensitive inversion recovery and STIR. In the thoracic cord, sensitivity values were 93.8% for STIR, 71.9% for FSE T2, and 50.8% for T1-weighted phase-sensitive inversion recovery. Significant differences were found for all comparisons (P < .05). No differences were detected in specificity. Poor image quality and lower sensitivity of thoracic T1-weighted phase-sensitive inversion recovery compared with the other 2 sequences were associated with a thicker back fat pad. CONCLUSIONS: The use of an additional sagittal sequence other than FSE T2 significantly increases the detection of cervical and thoracic spinal cord lesions in patients with MS at 3T. In the cervical segment, both STIR and T1-weighted phase-sensitive inversion recovery offer high sensitivity and specificity, whereas in the thoracic spine, STIR performs better than T1-weighted phase-sensitive inversion recovery, particularly in patients with a thick dorsal fat pad.

Use of a flow-diverting stent for ruptured dissecting aneurysm treatment in a patient with sickle cell disease.

INTRODUCTION: Sickle cell disease (SCD) is a clinical phenotype that presents a unique challenge to the interventionalist, particularly when stent therapy is contemplated. Homozygous individuals are likely at increased risk for thromboembolic complications. There are no formal guidelines regarding antiplatelet therapy in the short or long term for intracranial stent use in SCD. The authors describe the novel use of a pipeline embolization device (PED) to treat a ruptured dissecting bilobed/fusiform vertebral artery V4 aneurysm in an SCD patient complicated by tortuous proximal anatomy and the anterior spinal artery arising from the diseased segment. Considerations regarding antiplatelet therapy in this scenario are discussed. CASE REPORT: A 50-year-old woman with homozygous recessive SCD was transported to the emergency department and presented with diffuse subarachnoid hemorrhage. CT angiography demonstrated a left-sided 3 × 5 mm fusiform bi-lobulated presumed dissecting vertebral artery aneurysm, immediately distal to the origin of the posterior inferior cerebellar artery (PICA). A PED was deployed within the V4 segment across the aneurysm. Post-treatment angiography showed patency of the parent artery, and patency of the "jailed" anterior spinal artery and of the PICA. DISCUSSION: Selecting a treatment method in SCD patients with a ruptured intracranial aneurysm is challenging and there are no clinical trials comparing treatment methods in this population. The authors demonstrate that flow diversion is feasible in SCD, which has not been described in the literature. Additionally, the case stresses the peri- and post-procedural management of SCD, as well as long-term considerations with a flow-diverting stent in place.

Vascular wall imaging of vulnerable atherosclerotic carotid plaques: current state of the art and potential future of endovascular optical coherence tomography.

As stroke is one of the leading causes of death and long-term morbidity worldwide, the research community has studied cardiac embolic sources, as well as vessel wall pathologies. For the latter, attention has been focused on defining morphologic tissue features associated with catastrophic events stemming from the carotid artery. Multiple noninvasive imaging modalities are currently being used to image and classify carotid atherosclerotic plaques, such as MR imaging, CT, and sonography, in an effort to provide clinically relevant predictive metrics for use in patient risk stratification and to define appropriate treatment options. This article compares and contrasts these existing clinical imaging modalities along with discussion of a new endovascular technique originally developed for cardiology, OCT, with which 3D comprehensive high-resolution images of the arterial wall can be acquired.

Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms.

BACKGROUND AND PURPOSE: The PED is a flow-diverting stent designed for the treatment of cerebral aneurysms. We report 4 cases of delayed ipsilateral IPH following the technically successful treatment of anterior circulation aneurysms with the PED. MATERIALS AND METHODS: Clinical and imaging data from all patients undergoing aneurysm treatment with the PED at 2 institutions were analyzed to assess the incidence of delayed IPH after treatment with the PED. RESULTS: A total of 66 patients (47 anterior circulation) with cerebral aneurysms underwent treatment with a PED between January 2008 and November 2010. Four patients experienced delayed periprocedural IPH, all after the treatment of anterior circulation aneurysms (8.5%, 4/47). The aneurysm size ranged from 5 to 21 mm. All IPHs occurred within the cerebral hemisphere, ipsilateral to the treated aneurysm, and were anatomically remote from the treated aneurysms. All procedures were uncomplicated, and patients emerged from general anesthesia at neurologic baseline. The hemorrhages became clinically evident between 1 and 6 days after the procedure. Two patients had unfavorable outcomes (mRS scores, 4 and 6). CONCLUSIONS: Delayed IPH may occur after the treatment of anterior circulation aneurysms with flow diverters. This complication does not seem to be restricted to a specific aneurysm subtype and does not seem to be related to an intraprocedural complication or solely attributable to DAT.

Guidewire Tip Detachment during Stent-Assisted Coiling of an Intracranial Aneurysm. A Case Report.

SUMMARY: Endovascular treatment of complex intracranial lesions often requires use of two different microcatheters or micro-guidewires. A basilar artery aneurysm was treated with microstent-assisted coiling. During the procedure a microwire severed and the distal platinum portion of the wire was left after unsuccessful attempts to retrieve it. The patient remains asymptomatic. The proximal part of the microwire was analyzed and additional experiments indicate that it may have detached by electrolytic corrosion.

Shotgun pellet embolization to the posterior cerebral circulation.

The embolization of missiles to the intracranial circulation is a rare event. We describe here a case of a man shot by a shotgun, presenting with a posterior fossa stroke and occlusion of the superior cerebellar artery by a metallic pellet. To our knowledge, this is the third case of posterior fossa circulation pellet emboli.

Embolisation of Small (< 3 cm) Brain Arteriovenous Malformations. Correlation of Angiographic Results to a Proposed Angioarchitecture Grading System.

SUMMARY: The role of embolisation in the treatment of small < 3cm) brain arteriovenous malformations (AVMs) has not been elucidated. We reviewed our experience using embolisation in the treatment of small AVMs and correlated a proposed grading system based on the angioarchitecture to the percentage obliteration achieved by embolisation. Eighty-one small AVMs in 80 patients were embolised from 1984 to 1999. The age range was from 3 to 72 years. The AVMs were given a score from 0 to 6 based on the angioarchitecture. The assigned scores were as follows: nidus (fistula = 0, < 1 cm = 1, 1-3 cm = 2), type offeeding arteries (cortical = 0, perforator or choroidal = 1), number of feeding arteries (single = 0, multiple = 2) and number of draining veins (single = 0, multiple = 1). Angiographic results based on percentage obliteration were grouped into three categories: complete, 66-99%, and 0-65%. The goal of embolisation was cure in 27 AVMs, pre-surgical in 23, pre-radiosurgery in 26, and elimination of an aneurysm in five. Embolisation achieved complete obliteration in 22 (27%) of the 81 AVMs. In the AVMs where the goal was cure, 19 (70%) of 27 were completely obliterated. In the AVMs with angioarchitecture scores of 0-2, 12 (86%) of 14 were cured, with scores of 3-4, 8 (34%) of 24 were cured and with scores of 5-6, 2 (4%) of 44 were cured. Embolisation resulted in transient morbidity of 5.0%, permanent morbidity of 2.5%, and mortality of 1.2%. There were no complications in AVMs with scores of 0-2. Embolisation is an effective treatment of small AVMs when the angioarchitecture is favourable (scores 0-2). This includes pure fistulas and AVMs with a single, pial, feeding artery.

Hypertrophic olivary degeneration: metaanalysis of the temporal evolution of MR findings.

BACKGROUND AND PURPOSE: Hypertrophic olivary degeneration (HOD) is usually caused by a lesion in the triangle of Guillain and Mollaret and presents clinically as palatal tremor. Although the imaging features have been well described, the temporal course of hypertrophy and T2 signal increase in the inferior olivary nucleus (ION) has not been fully characterized. Our purpose was to evaluate the time course of MR imaging features of HOD caused by a lesion within the triangle of Guillain and Mollaret. METHODS: The temporal progression of HOD in 45 patients with symptomatic palatal tremor was obtained by extrapolation of combined MR imaging data from six patients treated at our institution and 39 patients reported in the literature. The MR examinations and reports were reviewed for presence of hyperintense signal in the ION on T2-weighted images, hypertrophy of the ION, and an inciting lesion in the triangle of Guillain and Mollaret. The interval between the MR examination and the inciting lesion was determined. RESULTS: Increased olivary signal on T2-weighted images first appeared 1 month after the inciting lesion and persisted for at least 3 to 4 years. Olivary hypertrophy initially developed 6 months after the acute event and resolved by 3 to 4 years. CONCLUSION: Visible changes on MR images in the ION in patients with a lesion in the triangle of Guillain and Mollaret correlate well with the described sequential histopathologic findings.

Dissecting aneurysms of the posterior cerebral artery: angioarchitecture and a review of the literature.

Isolated dissecting aneurysms of the posterior cerebral artery are not as rare as previously reported. Affecting primarily a younger population, this condition can be recognized by angiographic patterns, the most common being a "pearl and string" morphology. We reviewed the literature and present a series of six cases, discussing management strategies.

Palliative embolisation of brain arteriovenous malformations presenting with progressive neurological deficit.

SUMMARY: Large arteriovenous malformations (AVMs) located in eloquent areas of the brain are generally considered incurable because of the high morbidity and mortality associated with their treatment. When these patients develop a progressive neurological deficit they in time often become severely disabled. This report presents the results of palliative embolisation in this subgroup of patients. Analysis of our data-base of 714 patients with known brain AVMs revealed 17 patients who presented with progressive neurological deficit and who underwent palliative embolisation as the therapeutic modality of choice for management of their AVM. One patient was excluded due to lack of follow-up and two were excluded because they later received radiation therapy. Following embolisation 43% had improvement of their neurological deficit, 50% stabilized and 7% continued to deteriorate and these clinical results persisted for an average of more than 2 years follow-up. Transient neurological morbidity associated with embolisation treatment was 7% and there was no permanent morbidity and no mortality. Palliative embolisation of brain AVMs presenting with progressive neurological deficits arrested deterioration in more than 90% of patients and was associated with low morbidity and no mortality.

Endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils.

OBJECT: To describe the clinical and angiographic results of endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils, and to identify factors which should be considered in deciding upon surgical or endovascular treatment. METHODS: We report our experience with 40 patients in whom occlusion of basilar bifurcation aneurysms with electrolytically detachable coils was attempted. All patients underwent superselective angiography and attempted embolization with Guglielmi detachable coils (GDCs). Angiographic and clinical results were prospectively recorded. Twenty-eight aneurysms presented with subarachnoid hemorrhage (SAH), 2 were symptomatic and 10 were incidental. RESULTS: Coils were not placed in 10 patients (25%) because of unfavorable anatomy. Complete aneurysm occlusion was achieved at the time of the initial procedure in 13 (32.5%), small neck remnants were present in 13 (32.5%), and in 4 (10.0%) there was obvious residual contrast filling of the aneurysm body. Of 23 patients successfully coiled after SAH, 20 were Grade 1 to 3 and 3 were grade 4 or 5 at the time of treatment. Eighteen (78%) made a good recovery. Procedural mortality was 2.5% and permanent morbidity was 7.5%. There were no permanent complications in patients with unruptured aneurysms. Complete aneurysm occlusion was possible in 10 (56%) of 18 aneurysms with small necks and 3 (14%) of 22 with large necks. Follow-up angiography in 25 of 28 surviving patients (mean, 12 months) demonstrated stability of all completely occluded aneurysms. Incompletely coiled aneurysms had variable results on follow-up angiograms: 15.4% improved, 69.2% worsened, and 15.4% were stable. No aneurysm bled after treatment during clinical follow-up averaging 22 months. CONCLUSIONS: Endovascular treatment of basilar bifurcation aneurysms appears to prevent early aneurysm rebleeding with acceptable rates of morbidity and mortality, but long-term follow-up is required.

Tortuous, engorged pial veins in intracranial dural arteriovenous fistulas: correlations with presentation, location, and MR findings in 122 patients.

BACKGROUND AND PURPOSE: Tortuous, engorged veins can be identified on the venous phase of the brain circulation in patients with venous congestion related to an intracranial dural arteriovenous fistula (DAVF). The term pseudophlebitic pattern (PPP) has been used to describe this finding. The purpose of this study was to determine the prevalence of PPP in patients with intracranial DAVF and to analyze the relationship of this sign to presentation, location of the fistula, presence of retrograde leptomeningeal venous drainage, and MR findings. METHODS: We retrospectively reviewed the charts and imaging findings of 130 patients with intracranial DAVF. In 122 patients the venous phase of the brain circulation was adequately assessed. The PPP was graded as mild, moderate, or severe. RESULTS: PPP was found in 51 patients (42%). Thirty-two (73%) of the 44 patients who had a hemorrhage, neurologic deficit, or seizure had PPP as compared with 16 (21%) of the 75 who had a bruit or orbital signs. The three patients with either congestive heart failure or increasing head circumference had PPP. Fourteen (88%) of the 16 who had fistula of the superior sagittal sinus, straight sinus, or superior petrosal sinus had PPP. PPP was seen in 46 (81%) of 57 patients who had retrograde leptomeningeal venous drainage and in five (8%) of the 65 who had only sinosal drainage. Fourteen (88%) of the 16 who had white matter T2 hyperintensity on MR images had severe PPP. CONCLUSION: The PPP reflects venous congestion and is associated with an aggressive presentation with or without retrograde leptomeningeal venous drainage. PPP may be a useful prognostic indicator and should be considered in treatment decisions.

Paravertebral arteriovenous malformations with epidural drainage: clinical spectrum, imaging features, and results of treatment.

BACKGROUND AND PURPOSE: Arteriovenous malformations (AVMs) of the spine or spinal cord can be characterized as spinal cord AVMs, spinal cord and dural arteriovenous fistulas, and AVMs occurring outside the dura but draining into the epidural veins. The purpose of this study was to review the clinical spectrum, imaging features, and results of treatment of paravertebral arteriovenous malformations (PVAVMs) with epidural drainage. METHODS: The clinical records and images of 10 patients with PVAVMs were analyzed retrospectively for clinical presentation, MR findings, angioarchitecture, pathophysiology, treatment efficacy, and clinical follow-up. RESULTS: Seven patients had myelopathy. The MR findings for three of these patients showed spinal cord hyperintensity on T2-weighted sequences and prominent perimedullary vessels. Angiography, performed in two of the three patients, showed evidence of reflux into the perimedullary veins from the PVAVMs. Each of these two patients underwent surgical clipping of the radicular vein leading to the perimedullary veins. In three of the seven patients, there were large epidural veins compressing the cord. Angiography performed in these patients showed large PVAVMs with multiple feeders, which were treated by a combination of transarterial and transvenous embolization. One of the seven patients had an associated spinal cord arteriovenous malformation. In three patients with incidental PVAVMs, cure was achieved by using a combination of coils and liquid adhesives by the endovascular route. CONCLUSION: The clinical presentation of PVAVMs is variable, and symptomatic lesions are the result of compression by epidural veins or of congestive myelopathy. A clear understanding of the anatomy and pathophysiology is necessary to plan treatment. Endovascular techniques are capable of curing the malformation, alleviating the symptoms, or both in a significant proportion of these lesions.

A simple relationship between radiological arteriovenous malformation hemodynamics and clinical presentation: a prospective, blinded analysis of 31 cases.

OBJECT: The authors sought to establish prospectively whether there is a simple relationship between radiological features of brain arteriovenous malformation (AVM) hemodynamics and a patient's clinical presentation. METHODS: Thirty-one consecutive patients with AVMs underwent cerebral angiography at 3.8 frames/second during each standardized injection of contrast material. Contrast dilution curves were derived from the image sequences by using regions of interest (ROIs) traced on arteries feeding and veins draining the AVM nidus. Angiographic parameters were then analyzed in a blinded fashion. These parameters included the times required to reach the peak contrast density, the contrast decay time, and fractions thereof, in the ROI for each vessel. The authors determined whether these parameters, the arteriovenous transit time, and/or AVM size were related to patients' presentation with hemorrhage (11 patients), seizure (11 patients), or other clinical symptoms (nine patients). Statistically significant results were found only in analyses of arterial phase times to reach peak contrast density. Analyses of venous parameters, AVM size, and nidus transit time showed trends but no statistical significance. Arterial filling with contrast material was significantly slower in patients presenting with hemorrhage (mean 50%, 80%, and 100% of time to peak +/- standard error [SE] = 1.19+/-0.13, 1.97+/-0.18, and 3.04+/-0.34 seconds, respectively) compared with patients presenting with seizures (mean 50%, 80%, and 100% of time to peak +/- SE = 0.80+/-0.12, 1.32+/-0.18, and 1.95+/-0.29 seconds, respectively) according to analysis of variance (p<0.05) and post-hoc t-tests (p<0.05) for each parameter. Patients who presented with other symptoms had intermediate arterial filling times. CONCLUSIONS: These simple hemodynamic parameters, which can be obtained without added risk to the patient, may help identify a subset of individuals in whom AVMs pose a higher risk of future hemorrhage and who may therefore warrant more expeditious treatment.

Spontaneous vertebrovertebral arteriovenous fistulae clinical features, angioarchitecture and management of twelve patients.

SUMMARY: Spontaneous vertebrovertebral arteriovenous fistula (SVVAVF) is a rare condition which often presents as a bruit. We reviewed the clinical and imaging records of 12 patients with 13 SVVAVF fistulae who were managed at our institution over the last 14 years. Two patients had predisposing conditions, neurofibromatosis in one and Ehlers-Danlos syndrome in the other. Nine of the patients presented with a bruit; one patient presented with a myelopathy and one with congestive cardiac failure. Six of the 13 fistulae were at Cl and five of these six were children. 1n seven of the fistulae there was retrograde flow in the distal vertebral artery. Eight patients underwent endovascular treatment. Six required both contralateral and ipsilateral vertebral artery approaches. Coils (two patients), balloons (three patients), or a combination of agents including liquid adhesives (three patients) were used. Preservation of the vertebral artery was possible in three of the eight patients. Angiographic obliteration was obtained in all eight patients. There were no significant procedure-related complications. Embolisation is the primary treatment of SVV AVF and can be performed successfully with low morbidity. Preservation of the vertebral artery, although desired, is often not possible.

Central nervous system imaging. When is CT more appropriate than MRI?

Over the past 25 years, the development of noninvasive imaging techniques has allowed exquisite display of the anatomic structures of the brain and spinal cord in normal and disease states. CT remains useful because of short imaging times, widespread availability, ease of access, sensitive detection of calcification and hemorrhage, and resolution of bony detail. MRI offers superior soft-tissue contrast, excellent visualization of vascular structures, fewer artifacts, and imaging in any plane. Cost and use of ionizing radiation are considerations in choosing the most appropriate procedure. In the future, CT and MRI applications that concentrate on functional and physiologic display of the CNS will add greatly to the clinical utility of these imaging tools.

Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage.

OBJECT: The goal of this study was to develop a classification system for aneurysms associated with arteriovenous malformations (AVMs) based on their anatomical and pathophysiological relationships and to determine the incidence and bleeding rates for these aneurysms as well as the effects of AVM treatment on their natural history. METHODS: Of 632 patients with AVMs, intranidal aneurysms were found in 35 (5.5%) and flow-related aneurysms in 71 (11.2%). Patients with intranidal aneurysms presented more frequently with hemorrhage (72% compared with 40%, p < 0.001) and had a 9.8% per year risk rate of bleeding during follow-up review. Twelve (17%) of the patients with flow-related aneurysms associated with an AVM presented with hemorrhage from an aneurysm, whereas 15 (21%) bled from their AVM. Seventeen patients underwent angiography after AVM treatment (mean 2.25 years). Of 23 proximal aneurysms, 18 (78.3%) were unchanged, four (17.4%) were smaller, and one (4.3%) had disappeared, whereas four (80%) of five distal aneurysms regressed completely and one was unchanged. Sixteen patients underwent angiography after partial AVM treatment (mean 3.8 years). In cases with less than a 50% reduction in the AVM, no aneurysms regressed, although two enlarged and bled. In cases with greater than a 50% reduction in the AVM, two of three distal aneurysms disappeared and five proximal aneurysms were unchanged. CONCLUSIONS: Arterial aneurysms associated with cerebral AVMs may be classified as intranidal, flow-related, or unrelated to the AVM nidus. Intranidal aneurysms have a high correlation with hemorrhagic clinical presentation and a risk of bleeding during the follow-up period that considerably exceeds that which would be expected in their absence. Patients with flow-related aneurysms in association with an AVM may present with hemorrhage from either lesion. Aneurysms that arise on distal feeding arteries near the nidus have a high probability of regressing with substantial or curative AVM therapy.

Paediatric spinal arteriovenous malformations: angioarchitecture and endovascular treatment.

SUMMARY: This is a retrospective review of the clinical records and imaging of 14 children with spinal arteriovenous malformations referred to the neurointerventional service at our institution. The lesions are categorized by anatomic location into subpial (5 cases), epidural (3 cases), and paraspinal (6 cases). There were no dural arteriovenous fistulas in this group. The subpial lesions include both the intramedullary arteriovenous malformations (2 cases) and the perimedullary arteriovenous fistulas (3 cases). Two of the patients with perimedullary fistulas were first cousins and both had Rendu-Osler-Weber syndrome. The six paraspinallesions were vertebral-vertebral fistulas with five of these located at the first cervical metamere. Eleven cases (79%) were arteriovenous fistulas and three cases (21 %) were arteriovenous malformations with a nidus. There were nine (82%) high flow arteriovenous fistulae and two (18%) low flow arteriovenous fistulae. The ages range from seven months to 15 years, with a mean age of seven years. There were nine males and five females. Clinical presentations included: bruit alone (6 patients), progressive scoliosis (1 patient), pain (2 patients), neurologic deficit (4 patients) and one case of Cobb's syndrome. Management included: no treatment (1 patient), endovascular embolisation (10 patients) and surgery (3 patients). Of the patients who underwent endovascular treatment all were treated from the arterial side. Two patients were treated by N-butyl cyanoacrylate (NBCA) alone, two with NBCA and coils, one with balloons alone, three with balloons and coils and two with coils alone. In the endovascular treatment group, nine fistulae were completely obliterated (all high flow fistulae) and one patient had partial treatment (a spinal cord arteriovenous malformation). There were no complications from endovascular treatment.