Letter to the Editor. Microsurgical obliteration of a type IV spinal arteriovenous fistula with a hemostatic thrombin solution

Teresa Kalantari Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain

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Álvaro Zamarrón Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain

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Alberto Pérez de Vargas Martínez Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain

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Aurelio Vega Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain

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Celia Ortega-Angulo Central de la Defensa Gomez Ulla Hospital, Madrid, Spain

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Raquel Gutiérrez-González Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain

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TO THE EDITOR: We read with interest the article by Lara-Reyna et al.1 (Lara-Reyna J, Garst JR, Winslow N, et al. Microsurgical intraluminal obliteration of type IV perimedullary arteriovenous fistula with an in situ hemostatic agent: illustrative case. J Neurosurg Case Lessons. 2023;6[15]:CASE23322). The authors describe the occlusion of a type IV perimedullary arteriovenous fistula using an intraluminal hemostatic agent (without a clipping procedure). We would like to share a similar experience because of its rarity but apparent efficiency.

A 62-year-old female presented with acute gait instability. The day before, she had suffered sudden middorsal, interscapular pain. She also referred to sphincteric retention and inguinal sensory alteration. The neurological examination evidenced mild paresis (4/5) of both lower limbs (left predominance). Osteotendinous reflexes were exalted, and bilateral clonus was present.

Magnetic resonance imaging (MRI) showed a spinal subdural collection from C5 to S1. A focal anterior lesion was observed at T8–9 with contrast enhancement. The patient underwent an emergent T8–9 laminectomy and subdural hematoma evacuation. The case was completed with an angiography that revealed a type IV perimedullary arteriovenous fistula with an afferent vessel from the right T9 radiculomedullary artery and early venous drainage posterior and inferiorly. A venous aneurysm was also observed, anterior and superior to the fistula. The patient recovered motor and sphincteric function after surgery.

A posterior approach was scheduled. An organized hematoma surrounded the radiculomedullary artery, preventing identification of the vein foot. Moreover, motor evoked potentials (MEPs) significantly decreased in the right leg muscles, so the surgical procedure was stopped. The patient showed initial weakness of the right leg (3/5), but significant improvement was attained with rehabilitation therapy. A new attempt was performed 1 month later, when no hematoma was present. The fistula was identified and confirmed with Doppler ultrasound and intraoperative video-angiography. During the dissection maneuvers, discrete bleeding of the venous aneurysmal sac appeared on several occasions and was controlled with the application of a hemostatic agent (Floseal, Baxter). The inflammatory arachnoiditis prevented safe separation of the vessel from the anterior plane of the spinal cord, so the procedure was stopped after confirming MEP amplitude decrease in the right inferior limb. The patient immediately had improved motor and sensory functions after the last procedure and continued postoperative rehabilitation therapy. One-month follow-up angiography showed the absence of the arteriovenous fistula and venous aneurysm. Three-month follow-up MRI showed no focal anterior T8–9 lesion.

Even though the maneuver was unintentional in our case, the use of hemostatic agents was an effective strategy in the occlusion of the fistula, an outcome also observed in the patient described by Lara-Reyna et al.1 The intraoperative administration of Floseal (a human thrombin solution) may gradually reduce the flow, accomplishing retrograde thrombosis of the fistula. That would explain the absence of flow with Doppler at the end of the surgery and the neurological improvement demonstrated immediately after the last procedure, when the vascular steal phenomenon provoked by the fistula was interrupted.

Supplemental Information

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

References

1

Lara-Reyna J, Garst JR, Winslow N, Klopfenstein JD. Microsurgical intraluminal obliteration of type IV perimedullary arteriovenous fistula with an in situ hemostatic agent: illustrative case. J Neurosurg Case Lessons. 2023;6(15):CASE23322.

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    Lara-Reyna J, Garst JR, Winslow N, Klopfenstein JD. Microsurgical intraluminal obliteration of type IV perimedullary arteriovenous fistula with an in situ hemostatic agent: illustrative case. J Neurosurg Case Lessons. 2023;6(15):CASE23322.

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