Devoted to diagnostic and interventional spine imaging and therapeutics

Library

Spinal Avm: An Important Cause Of Intracranial Subarachnoid Hemorrhage In Children 2014

Category Interventional Mahmoud Zahra Robert Hurst Anne Marie Cahill Ganesh Krishnamurthy Hamza Shaikh Phillip Storm Purpose The purpose of this case is to illustrate that spinal AVM should be listed among the differential diagnoses for intracranial subarachnoid hemorrhage in children. Materials & Methods We report a 13 year female with no significant past medical history who presented with headache and fall. The patient reported a history of fall with mild head trauma, without loss of consciousness one day prior to admission. Clinical examination in the emergency department showed the patient to be drowsy but easily arousable and following commands. The cranial nerves were intact. There was severe weakness and sensation loss bilaterally in the lower extremities, with only toe movement preserved on the left. There was a sensory level at T5. Upper extremity examination was normal bilaterally. Results CT imaging of the brain demonstrated subarachnoid hemorrhage, primarily around the brain stem and foramen magnum with mild hydrocephalus. The location of subarachnoid hemorrhage involving the posterior fossa and foramen magnum combined with neurologic deficits involving the bilateral lower extremities and T5 sensory level raised concerns for a lesion involving the spinal cord. MRI of the spine demonstrated intramedullary spinal hemorrhage at T5 surrounded by edema and multiple enlarged vessels. Extensive spinal subarachnoid hemorrhage was also present. The appearance was consistent with rupture of a spinal cord AVM. An enlarged vessel drained superiorly along the ventral aspect of the cord into the posterior fossa, likely representing venous drainage for the AVM. Following MRI, repeat neurological examination revealed no movement of the lower extremities or sensation below T5. Spinal angiogram demonstrated a spinal arteriovenous malformation supplied primarily by bilateral T5 and T6 intersegmental arteries feeding both anterior and posterior spinal artery supply. The right T6 intersegmental artery was the largest AVM feeder via an anterior spinal artery directly into the AVM with no normal spinal supply visualized. The enlarged spinal supply to the AVM also harbored 2 fusiform aneurysms. This AVM supply and the aneurysms were embolized with NBCA with complete occlusion of the aneurysms and portion of the AVM fed by the vessel. Spinal AVM images.pptx Conclusion In conclusion: Spinal AVM is an important consideration in cases of nontraumatic intracranial subarachnoid hemorrhage in children. Spinal cord AVMs are frequently associated with feeding artery aneurysms which may be a source of subarachnoid hemorrhage. Biondi et al. found feeding artery aneurysms associated with 20% of intramedullary spinal cord AVMs. Importantly, the presence of an aneurysm carried a statistically significant increase in the risk of hemorrhage (AJNR Am J Neuroradiol. 1992 May-Jun;13(3):913-22.). Early diagnosis and treatment are crucial to decrease the associated morbidity and mortality. References 1.Biondi A, Merland JJ, Hodes JE, Pruvo JP, Reizine D, Aneurysms of spinal arteries associated with intramedullary arteriovenous malformations. I. Angiographic and clinical aspects. 2.Lv X, Li Y, Yang X, Jiang C, Wu Z, Endovascular embolization for symptomatic perimedullary AVF and Intramedullary AVM: a series and a literature review. 3.Madhugiri VS, Ambekar S, Roopesk Kumar VR, Sasidharan GM, Nanda A, Spinal aneurysms: clinicoradiological features and management paradigms.