Spinal glomus-type arteriovenous malformations: microsurgical treatment in 20 cases

Clinical article

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Object

Glomus-type spinal arteriovenous malformations (AVMs) are rare. In the literature only small series and anecdotal reports can be found, and there are no prospective series elucidating the natural course or the superiority of 1 treatment regimen over another (such as surgery versus embolization versus conservative treatment). Microsurgical treatment of spinal AVMs often seems difficult because many lesions are not anatomically suitable for primary microsurgical occlusion and are therefore treated with first-line neuroradiological interventions or not at all.

Methods

Between 1989 and 2005, 20 patients with glomus-type AVMs underwent microsurgical treatment at 2 major neurosurgical centers in Germany. The history of symptoms in these patients ranged from 2 days to 11 years. Four patients presented with subarachnoid hemorrhage, 2 with intramedullary hematoma, 4 with paresthesia or pain, and 10 with clinical signs of myelopathy. Seven patients underwent partial embolization prior to microsurgery. The authors only operated on AVMs accessible from a dorsal or dorsolateral approach. Neurological status was assessed with the McCormick classification scheme. Follow-up data were obtained from outpatient records. Three patients were interviewed over the telephone and 4 patients were not available for follow-up evaluation.

Results

Surgery was performed via a laminectomy in 14 and hemilaminectomy in 6 patients. The microsurgical technique used consisted of retrograde dissection of the AVM from the venous side in most cases. Four (20%) of 20 patients showed worsening of neurological symptoms to a worse McCormick grade, probably caused by suspected venous stasis directly after surgery, however only 1 patient (5%) suffered permanent deterioration after surgery. In 14 patients postoperative angiography proved complete occlusion in 11 patients, including the presence of a remnant requiring a second operation with complete occlusion thereafter in 1 patient. In 3 patients occlusion was incomplete: a small residual AVM remained in 1 patient, and a discrete feeding vessel without a vein was evident in 2 patients.

Conclusions

Spinal cord AVMs are rare. If embolization is not possible, surgery may be indicated in selected cases. Spinal AVMs behave differently after incomplete occlusion either surgically or with embolization. A postoperative reduction in symptoms is frequent despite the presence of small remnants, and the risk of neurological deficits seems relatively low even in residual AVMs. Therefore, treatment need not necessarily aim at complete occlusion if that would be associated with an unacceptably high risk of neurological deficits.

Abbreviations used in this paper: AVM = arteriovenous malformation; DS = digital subtraction; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Azize Boström, M.D., Department of Neurosurgery, University of Bonn Medical Center, Sigmund-Freud-Str. 25, 53105 Bonn, Germany. email: azize.bostroem@ukb.uni-bonn.de.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 10. Images obtained in a 45-year-old woman who presented with spinal SAH. The preoperative DS angiogram reveals a plexiform AVM of the conus medullaris region (anteroposterior projection A1–A3; lateral view B1 and B2). The postoperative DS angiogram (C) shows the complete occlusion of the AVM without any remaining pathological vessels.

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    Case 9. Images obtained in a 30-year-old man who presented with SAH and paraparesis. Preoperative DS angiograms (anteroposterior, A1–4; lateral, B1 and 2) and MR image (C) demonstrating a glomus-type AVM of the thracolumbar region (T12–L1). Coil embolization was performed preoperatively. The postoperative DS angiograms (D1–5) revealed incomplete microsurgical occlusion after embolization. In the operation report the surgeon described mainly venous occlusion. Arrow in D2 indicates normal filling of the segmental artery. Arrows in D3 indicate a discrete hyperemia with a small arterial feeding vessel but no early draining vein.

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