- Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
Division of Interventional Neuroradiology, Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
DOI:10.4103/2152-7806.85978Copyright: © 2011 Santillan A. 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: Santillan A, Zink W, Patsalides A, Gobin YP. Thoraco-lumbar artery aneurysms associated with a metameric paraspinal lesion presenting with retroperitoneal hemorrhage: Endovascular management. Surg Neurol Int 12-Oct-2011;2:137
How to cite this URL: Santillan A, Zink W, Patsalides A, Gobin YP. Thoraco-lumbar artery aneurysms associated with a metameric paraspinal lesion presenting with retroperitoneal hemorrhage: Endovascular management. Surg Neurol Int 12-Oct-2011;2:137. Available from: http://sni.wpengine.com/surgicalint_articles/thoraco-lumbar-artery-aneurysms-associated-with-a-metameric-paraspinal-lesion-presenting-with-retroperitoneal-hemorrhage-endovascular-management/
Background:Retroperitoneal hemorrhage is a life-threatening condition. This is the first reported case of rupture of one of multiple thoraco-lumbar artery aneurysms associated with a metameric paraspinal vascular lesion.
Case Description:A 77-year-old female patient presented to the emergency room with a new onset of left-sided low back pain shooting down the leg associated with weakness, numbness, and inability to walk. On physical examination, there was a notable left paraspinal swelling with a harsh bruit audible in the same area, left flank ecchymosis and a positive straight leg raising test. A computed tomography (CT) scan showed a large retroperitoneal hematoma. Digital subtraction angiography showed a large left paraspinal high-flow arteriovenous lesion, with large arterial aneurysms of the left T11, T12, and L1 segmental arteries. The patient was successfully treated with endovascular aneurysm embolization using coils and Onyx-34. Six months following the procedure, the patient had fully recovered, and a follow-up angiogram showed no residual or recurrent aneurysms.
Conclusion:Thoraco-lumbar artery aneurysms have never previously been described in association with a metameric paraspinal vascular malformation. We report a case of retroperitoneal hemorrhage due to rupture of one of several high-flow artery aneurysms of a paraspinal arteriovenous malformation (AVM). The diagnosis was made on CTA, MRI, and angiography, and the lesion was successfully treated by transarterial embolization.
Keywords: Arteriovenous malformation, endovascular embolization, metameric lesion, Onyx-34
Metameric paraspinal AVMs are exceptional and there are only a few reported cases in the literature.[
We report a rare case of a metameric paraspinal AVM associated with high-flow artery aneurysms presenting with retroperitoneal hemorrhage.
A 77-year-old Cantonese speaking female patient with a vague history of “back tumor” 15 years ago that was never biopsied, presented to the emergency room with a new onset of left-sided low back pain shooting down the leg associated with weakness, numbness, and inability to walk. She was also complaining of nausea and dizziness. The patient was hemodynamically stable (blood pressure 125/65 mmHg; pulse rate, 70/min) although her work-up revealed a hemoglobin of 7.8 g/dL. On physical examination, there was a notable left paraspinal swelling with a harsh bruit audible in the same area associated with tenderness in the thoracolumbar junction, left flank ecchymosis and a positive straight leg raising test. The patellar and Achilles tendon reflexes were normal and symmetric. There was no sensory disturbance. With a consideration for internal bleeding, fluid resuscitation, blood transfusion, and oxygen supplementation were administered. The patient received transfusion of 4 units of packed red blood cells and 1 unit of platelets. A computed tomography (CT) scan showed a large retroperitoneal hematoma [
(a) A non-contrast axial CT scan shows a large left-sided retroperitoneal hematoma (arrows) extending from T12 to L4 levels, and measuring 9.2 × 6.8 cm. (b) A sagittal T2-weighted MR image shows the paraspinal vascular lesion (arrowhead), and a hematoma in and around the left psoas muscle (black arrows) resulting from rupture of the left L1 feeding-artery aneurysm (thin arrow)
(a) A 3D CT angiography reveals large aneurysms originating from the left T11, T12, and L1 segmental arteries (arrows). (b) Sagittal T2-weighted MR showing a paraspinal vascular malformation with multiple flow-voids, and a direct communication (arrow) between the malformation and a T12 high-flow artery aneurysm
The patient was taken urgently to the angiography suite. From a right femoral artery access, a spinal angiography was performed. It demonstrated a large left paraspinal high-flow arteriovenous malformation (AVM), with large arterial aneurysms at the left T11, T12, and L1 segmental arteries [
Paraspinal AVMs are more commonly diagnosed in a pediatric population,[
In our patient, the paraspinal AVM had three large aneurysms arising from T11, T12, and L1 segmental arteries. The large hematoma located in the left psoas muscle, extending from T12 to L4 levels, probably occurred from rupture of one of these aneurysms, most likely the L1 segmental artery aneurysm since it was the largest, and had a very irregular shape. It is important to notice that there were no cutaneous vascular lesions in our patient, as if the lesion would have extended into the skin with its corresponding dermatomes; we could have diagnosed a Cobb syndrome.[
Retroperitoneal hemorrhage is a rare condition which requires a high index of clinical suspicion. It may occur as a complication of femoral angiography, ruptured abdominal aortic, iliac, renal, mesenteric, and ovarian artery aneurysms,[
The indications for treatment of paraspinal AVMs is usually based on common clinical findings, such as back pain, paravertebral murmur, high-output cardiac failure, paraparesis, or paraplegia (due to direct compression, steal phenomenon, intraspinal hemorrhage, or venous hypertension), dysphagia, and spinal instability with or without major spinal deformity.[
Endovascular management is an efficient treatment option for paraspinal AVMs.[
We present a unique case of an adult patient with thoraco-lumbar artery aneurysms associated with a metameric paraspinal arteriovenous malformation presenting with retroperitoneal hemorrhage due to rupture of one of multiple aneurysms. The lesion was diagnosed with CTA, MRI, and angiography, and successfully treated by endovascular embolization using coils and Onyx-34. Transarterial embolization was the therapeutic approach of choice in the reported case provided the patient was hemodynamically stable. Observation of the residual vascular malformation will be necessary because additional embolization or surgical treatment might be needed by the patient in the future.
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