Spinal fistulas documented by contrast enhanced computed tomography during myelopathy workup: a lost opportunity
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SPINAL NEURORADIOLOGY
Spinal fistulas documented by contrast enhanced computed tomography during myelopathy workup: a lost opportunity Abderrahmane Hedjoudje 1,2,3
&
Olwen C. Murphy 1 & Lydia Gregg 1 & Carlos A. Pardo 1 & Philippe Gailloud 1
Received: 5 June 2020 / Accepted: 9 November 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Purpose Low-flow spinal arteriovenous fistulas (SAVFs) with intradural venous drainage typically manifest with a progressive venous hypertensive myelopathy (VHM) in older patients. VHM is difficult to identify. MRI is often nonspecific, and many cases are initially misdiagnosed, most often as transverse myelitis. The workup of myelopathic patients frequently includes thoracic and/or abdominal contrast-enhanced CT (CECT) that are generally not reviewed by neuroradiologists. The purpose of this work was to investigate how often abnormal enhancing intracanalar structures corresponding to the draining veins of a low-flow SAVF were documented by CECT. Materials and methods We evaluated 92 consecutive patients with low-flow SAVFs and VHM treated at our institution between 2009 and 2018. The study group included 22 of these patients with at least one thoracoabdominal CECT available for review. The control group consisted of 20 consecutive myelopathy patients with negative angiography and at least one thoracoabdominal CECT. Intracanalar enhancing structures were classified either as (i) conspicuous or (ii) equivocal or absent. Results One CECT in the study group was technically inadequate. Conspicuous intracanalar enhancing structures were observed in 20 of the remaining 21 patients with SAVFs (95.2%) and in 2 of 20 control patients (10%). None of the enhancing intracanalar structures was mentioned in official study reports. Conclusions The presence of enhancing vascular structures within the spinal canal on thoracoabdominal CECT obtained during the workup of myelopathies appears to represent a powerful but currently underappreciated tool for the detection of low-flow SAVFs. Keywords CT . Spinal arteriovenous fistulas . Myelopathy
Introduction Low-flow spinal arteriovenous fistulas (SAVF) are the most common spinal vascular malformations. They include spinal dural arteriovenous fistulas (SDAVF), low-flow perimedullary arteriovenous fistulas (PmAVF), and lowflow spinal epidural arteriovenous fistulas (SEAVF) (Fig. 1). Low-flow SAVFs likely develop in the context of local or
* Abderrahmane Hedjoudje [email protected] 1
Division of Interventional Neuroradiology and Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
2
Diagnostic and Interventional Radiology Department, Sion Hospital, Sion, Valais, Switzerland
3
Baltimore, USA
diffuse spinal venous thrombosis. The combination of low output and low pressure arteriovenous shunts with a lack of functional radiculomedullary draining veins (RMV) leads, through the development of venous congestion and hypertension, to a venous hypertensive myelopathy (VHM) [1, 2]. Low-fl
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