Introduction: Purpose: Spinal vascular malformations can result in spinal cord dysfunction and disability. A high index of clinical suspicion after correlating the patient’s history, physical exam, and imaging is necessary to establish diagnosis and further therapeutic options. Early recognition and treatment can halt progression of the disease and minimize permanent and possibly irreversible spinal cord injury. A variety of treatment modalities exist, including endovascular embolization or open surgery. Our surgical approach used in this case represents a recently described therapeutic modality, which could be implemented in similar cases.
Methods: Case description: 75-years-old female who presented to the Emergency Department with sudden, severe headaches and nuchal rigidity. Patient denied any history of trauma. Posterior fossa cerebral subarachnoid hemorrhage was diagnosed on non-contrast head computed tomography.
Clinical Approach: Subsequent DSA demonstrated a C2/3 left perimedullary arteriovenous fistula in the anterolateral cervical cord.
Results: Clinical findings: The AVF was supplied by left C2/C3 radiculomedullary artery feeders from the vertebral artery, with an associated arterialized venous varix. Drainage was via the anterior median spinal vein cranially. The patient underwent delayed treatment with laminectomies at C1 to C3, posterior transpedicular approach involving the C2 pedicle and C3 lateral mass with subsequent sectioning of the feeders and coagulation/occlusion of the perimedullary draining venous varix. Successful recovery with no neurologic sequelae was observed.
Conclusions: We present this rare entity and describe the diagnostic and surgical techniques utilized. Further discussion and review, the most appropriate time for management, possible approaches, and different classification systems are emphasized in our discussion.
Patient Care: By the conclusion of this session, participants should be able to: 1) Describe the importance of considering a spinal vascular malformation after a subarachnoid hemorrhage on initial imaging, 2) Discuss possible surgical treatments, including endovascular embolization vs open surgery, 3) Provide surgeons with better understanding of the pathology involved, as well as our management presented, including, team-based effort of spine neurosurgeons, as well as endovascular and vascular neurosurgeons.
Learning Objectives: Understand the current classification of spinal AVFs and discuss different therapeutic modalities.