PMC4533347_01
Cervical spine MRI (A, sagittal T2; B and C, axial T2). Abnormal flow void signals in the ventral surface and inside of the cervical spinal cord at the C3 to C5 levels. D: Angiogram before treatment. Selective angiogram of the right subclavian artery (anteroposterior view) showing perimedullary AVF and intramedullary AVM fed by the anterior spinal artery from the right vertebral artery and the right deep cervical artery, respectively. AVF: arteriovenous fistula, AVM: arteriovenous malformation, MRI: magnetic resonance imaging.
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F1
Low intensity signals, indicative of hemosiderin, associated with a previous hemorrhage within the spinal cord, were also noted (Fig. 1).
A: Selective angiography of the right vertebral artery (anteroposterior view) before focal fractionated radiotherapy, revealing intramedullary AVM fed by the ASA with multiple feeders. B: Selective angiography of the right deep cervical artery (anteroposterior view) before focal fractionated radio-therapy revealing perimedullary AVF and intramedullary AVM fed by the ASA. C: Selective angiographyof the right vertebral artery (anteroposterior view) after 5 years from irradiation, revealing the disappearance of the lesion that was fed by the right vertebral artery. D: Selective angiographyof the right right deep cervical artery (anteroposterior view) after 5 years from irradiation, a reduction in size of the nidus and the number of AV shunts. ASA: anterior spinal artery, AV: arteriovenous, AVF: arteriovenous fistula, AVM: arteriovenous malformation.
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F2
Spinal angiography revealed an intramedullary AVM and perimedullary arteriovenous fistula (AVF), both of which were fed by the right vertebral artery (Fig. 2A) and the deep cervical artery via ASA (Fig. 2B). Five years after irradiation, angiography demonstrated that the lesion, which was fed by the right vertebral artery had disappeared (Fig. 2C), and that the other lesion, which was fed by the right deep cervical artery, had been significantly reduced to size of the nidus and the number of AV shunts (Fig. 2D).
Cervical spine magnetic resonance imaging (A, sagittal T2; B and C, axial T2). Flow void signals and varix in the ventral surface at the C3 to C5 levels, reduction of nidus within the spinal cord.
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F3
MRI revealed that flow void signals, varix, and nidus dramatically had been reduced at the C3 to C5 level of the spinal cord (Fig. 3).
Hybrid operating room at Hokkaido University Hospital, Sapporo, Japan. Single-plane neuroangiographic digital subtraction angiography units.
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F4
Under general anesthesia, the patient was placed in the supine position within the hybrid OR with the neck slightly extended (Fig. 4).
A: Preprocedural anteroposterior angiogram of the right deep cervical artery confirming arterial supply to the spinal AVM via the ASA. B: Intraoperative photograph illustrating an extensive extrapial AVM nidus involving the anterior surface of the spinal cord and showing one of AV shunts (arrow). C: Indocyanine green videoangiography demonstrating early filling of the extra-pial draining vein (*) and ASA (+). D: Postprocedural anteroposterior angiogram of the right deep cervical artery, verifying complete AVM obliteration and patency of the ASA. E: Intraoperative photograph illustrating the color of the extra-pial draining vein which had changed from fresh red to dark red following coagulation of the AV shunts. F: Indocyanine green videoangiographycomfirms obliteration of the extra-pial draining vein and patency of the ASA (+). ASA: anterior spinal artery, AV: arteriovenous, AVF: arteriovenous fistula, AVM: arteriovenous malformation.
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F5
Complete obliteration of the fistulous connection was confirmed by ICG and intraoperative angiography, and the ASA was preserved (Fig. 5).