- Student, Medical College, Aga Khan University Hospital, Karachi, Pakistan
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
Muhammad E. Bari
Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
DOI:10.4103/2152-7806.96074Copyright: © 2012 Shallwani H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shallwani H, Tahir MZ, Bari ME, Tanveer-ul-Haq . Concurrent intracranial and spinal arteriovenous malformations: Report of two pediatric cases and literature review. Surg Neurol Int 14-May-2012;3:51
How to cite this URL: Shallwani H, Tahir MZ, Bari ME, Tanveer-ul-Haq . Concurrent intracranial and spinal arteriovenous malformations: Report of two pediatric cases and literature review. Surg Neurol Int 14-May-2012;3:51. Available from: http://sni.wpengine.com/surgicalint_articles/concurrent-intracranial-and-spinal-arteriovenous-malformations-report-of-two-pediatric-cases-and-literature-review/
Background:Concurrent intracranial and spinal arteriovenous malformations (AVMs) are very rare with only a few cases being reported in literature. Two of the rare concurrent intracranial and spinal AVM cases are presented.
Case Description:Case 1 is a 12-year-old girl with headache and motor disturbances in the lower limbs. Her spinal and brain angiogram was done and she was diagnosed to have a spinal AVM at level T8–T9 and an intracranial AVM in the left mesial temporal lobe. Her spinal AVM was embolized, while no treatment was given for her intracranial AVM. Case 2 is a 10-year-old girl who presented with headache and quadriparesis. Her brain and spinal angiogram revealed an intracranial AVM in the left parietal lobe and a spinal AVM at level C2, respectively. Craniotomy and excision was done for her intracranial AVM and embolization for the spinal AVM.
Conclusion:It is proposed that multiple AVMs may be a result of yet unrevealed pathogenesis or strong embryogenetic anomaly, which may be different from that involved in single AVM. With lack of consensus over the best therapeutic strategy, multimodality treatment based on the individual's needs is suggested.
Keywords: Arteriovenous malformation, cerebral, concurrent, intracranial, multiple, spinal
Single intracranial arteriovenous malformation (AVM) along with a spinal AVM is very rare with less than 10 cases being reported in literature since 1969. Multiple intracranial AVMs with a spinal AVM are even more infrequent; only three other cases have been reported in the literature, one being an autopsy case. We report two such uncommon cases involving an intracranial AVM along with a spinal AVM.
The first case of intracranial AVM along with a spinal AVM involves a 12-year-old girl who presented to us with a 3-month history of headache and progressively worsening spastic paraparesis with reflex spasms of both lower limbs. There was no history of lower back pain and no bladder or bowel disturbances. Examination showed power of 3/5 in the right lower limb and 4/5 in the left lower limb, with normal bulk but increased muscle tone. She also had brisk reflexes in both lower limbs. Cognitive functions, speech, and upper limb reflexes were normal, along with intact sensations and cerebellar functions. She had been in a good state of health in the past and her family history was negative for any hereditary vascular disorders or AVMs. Magnetic Resonance Imaging (MRI) of dorsolumbar spine showed epidural flow voids. Spinal angiogram showed an AVM in mid-dorsal region at level T8–T9 with three feeders comprising left 8th and right 9th and 10th intercostal arteries [
(a) Perimedullary arteriovenous malformation (AVM) located in mid dorsal region. (b) Post-contrast T1-weighted image showing concurrent AVM (black arrow) in left hippocampus. (c) MRA showing nidus (white arrow) supplied by left posterior cerebral artery. (d) Glue cast deposition in AVM after embolization
Spinal AVM embolization was carried out by polyvinyl acetate (PVA) and histoacryl particles under general anesthesia and complete embolization was achieved [
On follow-up after 1 year, the patient was doing well with no significant symptoms. She was able to work independently and did not require further treatment.
The second case of single intracranial AVM with concurrent spinal AV fistula involves a 10-year-old girl who presented to us with headaches and progressively increasing weakness of all four limbs for 2½ years. On examination, she had decreased bulk of muscles and increased tone in both upper and lower limbs. She also had brisk reflexes, upgoing planters, and clonus. She was quadriparetic with power of 3/5 in the right upper and lower limbs and 4/5 in the left half of body. She was otherwise conscious and well oriented to time, place, and person, and her sensations were intact. Her past history was unremarkable and there was no significant family history of any hereditary vascular disorder or AVMs. Her brain MRI and cerebral angiography revealed left parasagittal AVM of medium size in the parietal region with superficial venous drainage [Figure
(a) Left parietal arteriovenous malformation (AVM). (b) Left parasagittal AVM. (c) Post-procedure angiogram showing no residual AVM. (d) Perimedullary AV fistula with large aneurysm in cervical region (black arrow showing early filling vein, white arrow showing arterial feeder). (e) Large cervical aneurysm. (f) T2-weighted image showing cervical aneurysm (arrowhead) (white arrow showing high-intensity signals in spinal cord due to venous hypertension). (g) Post-embolization angiogram showing complete obliteration of AV fistula and aneurysm. (h) Post-glue embolization (black arrow showing glue deposited in arterial feeder)
After her cranial surgery, her symptoms recurred and she showed progressive weakness and signs of myelopathy in all four of her limbs. Angiography was repeated, which revealed an AV fistula in the cervical region [
Angiographic coiling of aneurysm was done and feeders from vertebral arteries and PICA were embolized. Tiny feeder from left costocervical artery was embolized with histoacryl glue. No residual AV fistula was seen in post-procedural angiography [Figure
On follow-up, the patient was doing well and the treatment of AV fistula seemed to be adequate. However, after 1 year and 4 months, the patient showed signs of mild weakness in left-sided upper and lower limbs. She was able to carry out most of the tasks independently; however, she limped while walking and had weakness of left hand and fingers. The patient refused further evaluation and management.
Multiple AVMs have been seen to be associated with hereditary disorders such as Rendu–Osler–Weber syndrome or hereditary hemorrhagic telangiectasia. It is extremely uncommon to see concurrent intracranial and spinal AVM not associated with such syndromes.
Single intracranial AVM along with a spinal AVM is very rare, with total number of cases reported in the literature being less than 10 since 1969.[
The age at presentation ranged from 1.3 to 55 years, with a mean age of 23.8 years. There were five males and six females. Six cases presented with subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), or intracerebral hemorrhage (ICH) as a result of hemorrhage from AVM. Out of the 19 intracranial AVMs whose size was known, there were 16 small and 3 medium intracranial AVMs. Moreover, out of the 17 lesions with known venous drainage, 15 intracranial AVMs had superficial and only 2 had deep venous drainage. The level of spinal AVM ranged from C1 to L2. There were four glomus, two dural, and one juvenile spinal AVMs.
AVMs are congenital lesions occurring between the fourth and eighth weeks of embryonic development when vessels differentiate into arteries, veins, and capillaries.[
Familial AVMs are extremely rare, manifesting at a younger age and occurring more frequently in females.[
AVM is known to produce harm by its rupture or rupture of an associated aneurysm, by causing seizures, or by causing ischemia of the adjacent brain matter by the steal phenomenon.[
The angioarchitectural factors that increase the risk of hemorrhage from an AVM include the presence of flow-related aneurysm, presence of intranidal aneurysm, deep venous drainage, deep (periventricular) location, small nidus size (<3 cm), high feeding artery pressure, slow arterial filling, and venous stenosis.[
Multiple AVMs can co-exist in brain and spinal cord, and can be difficult to detect and manage. We suggest that in cases where one lesion does not explain all the symptoms or if there is progressive worsening of symptoms, there should be a high index of suspicion for another lesion and further investigations are warranted. For patients with concomitant intracranial and spinal AVM, multimodality treatment tailored for individual cases currently seems to be the best approach.
1. Di Chiro G. Recent successes and failures in radiographic and radioisotopic angiography of the spinal cord. Br J Radiol. 1972. 45: 553-60
2. Di Chiro G, Doppman J, Ommaya AK. Selective arteriography of arteriovenous aneurysms of spinal cord. Radiology. 1967. 88: 1065-77
3. Di Chiro G, Wener L. Angiography of the spinal cord. A review of contemporary techniques and applications. J Neurosurg. 1973. 39: 1-29
4. Doppman JL, DiChiro G, Ommaya AK.editorsSelective Arteriography of the Spinal Cord. Warren H. Green: St. Louis; 1969. p.
5. Fisher WS, Wilkins RH, Rengachary SS.editors. Concomitant intracranial aneurysms and arteriovenous malformations. Neurosurgery. New York: McGraw-Hill; 1996. p. 2429-31
6. Fleetwood IG, Steinberg GK. Arteriovenous malformations. Lancet. 2002. 359: 863-73
7. Hasegawa S, Hamada JI, Morioka M, Kai Y, Takaki S, Ushio Y. Multiple cerebral arteriovenous malformations (AVMs) associated with spinal AVM. Acta Neurochir (Wien). 1999. 141: 315-9
8. Hash CJ, Grossman CB, Shenkin HA. Concurrent intracranial and spinal cord arteriovenous malformations. Case report. J Neurosurg. 1975. 43: 104-7
9. Hoffman HJ, Mohr G, Kusunoki T. Multiple arteriovenous malformations of spinal cord and brain in a child. Case report. Childs Brain. 1976. 2: 317-24
10. Kim H, Su H, Weinsheimer S, Pawlikowska L, Young WL. Brain arteriovenous malformation pathogenesis: A response-to-injury paradigm. Acta Neurochir Suppl. 2011. 111: 83-92
11. Krayenbühl H, Yaargil MG, McClintock HG. Treatment of spinal cord vascular malformations by surgical excision. J Neurosurg. 1969. 30: 427-35
12. Laakso A, Dashti R, Juvela S, Niemelä M, Hernesniemi J. Natural history of arteriovenous malformations: Presentation, risk of hemorrhage and mortality. Acta Neurochir Suppl. 2010. 107: 65-9
13. Mizutani T, Tanaka H, Aruga T. Multiple arteriovenous malformations located in the cerebellum, posterior fossa, spinal cord, dura, and scalp with associated port-wine stain and supratentorial venous anomaly. Neurosurgery. 1992. 31: 137-41
14. Moss JG, Sellar RJ, Hadley DM. Intracerebral and spinal vascular malformation in a patient without hereditary haemorrhagic telangiectasia. Neuroradiology. 1989. 31: 280-1
15. Parkinson D, West M. Spontaneous subarachnoid hemorrhage first from an intracranial and then from a spinal arteriovenous malformation. Case report. J Neurosurg. 1977. 47: 965-8
16. Pawlikowska L, Tran MN, Achrol AS, Ha C, Burchard E, Choudhry S. Polymorphisms in transforming growth factor-beta-related genes ALK1 and ENG are associated with sporadic brain arteriovenous malformations. Stroke. 2005. 36: 2278-80
17. Rothbart D, Awad IA, Lee J, Kim J, Harbaugh R, Criscuolo GR. Expression of angiogenic factors and structural proteins in central nervous system vascular malformations. Neurosurgery. 1996. 38: 915-25
18. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986. 65: 476-83
19. Tamaki N, Fujita K, Yamashita H. Multiple arteriovenous malformations involving the scalp, dura, retina, cerebrum, and posterior fossa. Case report. J Neurosurg. 1971. 34: 95-8
20. Tsurushima H, Meguro K, Matsumura A, Narushima K, Nakada Y, Nose T. Multiple arteriovenous malformations of spinal cord and brain in a child. Pediatr Neurosurg. 1995. 23: 166-70
21. Uranishi R, Baev NI, Ng PY, Kim JH, Awad IA. Expression of endothelial cell angiogenesis receptors in human cerebrovascular malformations. Neurosurgery. 2001. 48: 359-68
22. Wang Y, Zhang H, Ling F. Coexistence of a single cerebral arteriovenous malformation and spinal arteriovenous malformation. Neurol India. 2009. 57: 785-8
23. Weinsheimer S, Kim H, Pawlikowska L, Chen Y, Lawton MT, Sidney S. EPHB4 gene polymorphisms and risk of intracranial hemorrhage in patients with brain arteriovenous malformations. Circ Cardiovasc Genet. 2009. 2: 476-82
24. Wong JH, Awad IA, Kim JH. Ultrastructural pathological features of cerebrovascular malformations: A preliminary report. Neurosurgery. 2000. 46: 1454-9
25. Yokoyama K, Asano Y, Murakawa T, Takada M, Ando T, Sakai N. Familial occurrence of arteriovenous malformation of the brain. J Neurosurg. 1991. 74: 585-9