Answer for BIR CoW 12 Jan 2025
THROMBOSED POSTERIOR EPIDURAL ARTERIOVENOUS MALFORMATION
Findings
T1/ T2 heterointense solid cystic lesion with diffusion restriction in posterior extradural plane of spinal cord at D5 – D7 level causing severe spinal canal compromise with narrowest diameter of spinal canal measuring 3.8 mm at D5 – D6 level. The lesion extends across the left D5 – D6 neural foramen into left paraspinal space abutting the posteromedial aspect of descending thoracic aorta. The lesion shows heterogenous contrast enhancement with internal foci of gradient blooming. Posterior dural enhancement noted from D3 – D8 level.
Discussion
Spinal arteriovenous malformations (SAVMs) are rare congenital high-flow vascular lesions accounting for about 10–15 % of all spinal vascular shunts . SAVMs may occur as sporadic or in the setting of genetic syndromes. Clinical features: Clinical presentation is variable, ranging from progressive myelopathy often with delayed diagnosis, to catastrophic spinal subarachnoid hemorrhage . Hematomyelia occurs in approximately one-half of patients and manifests with severe back, neck, or radicular pain along with sensorimotor/autonomic deficits corresponding to the spinal level involved (mostly thoracic). In non-hemorrhagic spinal AVMs, gradual myelopathic symptoms occur as result of mass effect, vascular steal, venous thrombosis, or venous congestion. Classification: Spinal AVMs can be classified into: 1.Compact intradural intramedullary glomus AVM (type II) 2.Mixed extradural-intradural intramedullary juvenile AVM (type III). Intramedullary glomus-type AVMs consist of an intramedullary nidus of shunting vessels usually located in the anterior half of the spinal cord fed by one or more spinal arteries, draining into spinal veins. Most of SAVMs are confined in the thoracic spine . Intranidal or arterial aneurysms are common, found in up to 30–40 % of SAVMs and responsible of subarachnoid hemorrhage or hematomyelia, experienced in over half of patients with SAVMs. Imaging : Conventional angiography is the gold standard for diagnosis and assessment of SAVMs. DSA allows recognition of feeding arteries and draining veins, provides information on the extension of the nidus and his relationship with feeding vessels, as well as enables the identification of fragility points as arterial aneurysms, pseudoaneurysms or fistula points. Treatment: Endovascular embolization and surgery are the therapeutic choices for spinal AVMs, although the eradication could be often incomplete and the risk for spinal cord ischemia increased. Stereotactic radiosurgery can be curative in some cases or facilitates the lesion’s shrinking
REFERENCES:
1.Da Ros V, Picchi E, Ferrazzoli V, Schirinzi T, Sabuzi F, Grillo P, Muto M, Garaci F, Muto M, Di Giuliano F. Spinal vascular lesions: anatomy, imaging techniques and treatment. Eur J Radiol Open. 2021 Jul 14;8:100369. doi: 10.1016/j.ejro.2021.100369. 2. Minami S, Sagoh T, Nishimura K et-al. Spinal arteriovenous malformation: MR imaging. Radiology. 1988;169 (1): 109-15
Findings
T1/ T2 heterointense solid cystic lesion with diffusion restriction in posterior extradural plane of spinal cord at D5 – D7 level causing severe spinal canal compromise with narrowest diameter of spinal canal measuring 3.8 mm at D5 – D6 level. The lesion extends across the left D5 – D6 neural foramen into left paraspinal space abutting the posteromedial aspect of descending thoracic aorta. The lesion shows heterogenous contrast enhancement with internal foci of gradient blooming. Posterior dural enhancement noted from D3 – D8 level.
Discussion
Spinal arteriovenous malformations (SAVMs) are rare congenital high-flow vascular lesions accounting for about 10–15 % of all spinal vascular shunts . SAVMs may occur as sporadic or in the setting of genetic syndromes. Clinical features: Clinical presentation is variable, ranging from progressive myelopathy often with delayed diagnosis, to catastrophic spinal subarachnoid hemorrhage . Hematomyelia occurs in approximately one-half of patients and manifests with severe back, neck, or radicular pain along with sensorimotor/autonomic deficits corresponding to the spinal level involved (mostly thoracic). In non-hemorrhagic spinal AVMs, gradual myelopathic symptoms occur as result of mass effect, vascular steal, venous thrombosis, or venous congestion. Classification: Spinal AVMs can be classified into: 1.Compact intradural intramedullary glomus AVM (type II) 2.Mixed extradural-intradural intramedullary juvenile AVM (type III). Intramedullary glomus-type AVMs consist of an intramedullary nidus of shunting vessels usually located in the anterior half of the spinal cord fed by one or more spinal arteries, draining into spinal veins. Most of SAVMs are confined in the thoracic spine . Intranidal or arterial aneurysms are common, found in up to 30–40 % of SAVMs and responsible of subarachnoid hemorrhage or hematomyelia, experienced in over half of patients with SAVMs. Imaging : Conventional angiography is the gold standard for diagnosis and assessment of SAVMs. DSA allows recognition of feeding arteries and draining veins, provides information on the extension of the nidus and his relationship with feeding vessels, as well as enables the identification of fragility points as arterial aneurysms, pseudoaneurysms or fistula points. Treatment: Endovascular embolization and surgery are the therapeutic choices for spinal AVMs, although the eradication could be often incomplete and the risk for spinal cord ischemia increased. Stereotactic radiosurgery can be curative in some cases or facilitates the lesion’s shrinking
REFERENCES:
1.Da Ros V, Picchi E, Ferrazzoli V, Schirinzi T, Sabuzi F, Grillo P, Muto M, Garaci F, Muto M, Di Giuliano F. Spinal vascular lesions: anatomy, imaging techniques and treatment. Eur J Radiol Open. 2021 Jul 14;8:100369. doi: 10.1016/j.ejro.2021.100369. 2. Minami S, Sagoh T, Nishimura K et-al. Spinal arteriovenous malformation: MR imaging. Radiology. 1988;169 (1): 109-15
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!