Conus Medullaris AVM

Spetzler et al.1 have proposed the conus medullaris AVM as a new category characterized by multiple feeding arteries, multiple niduses, and

Wakhloo Ajay

Figure 16.3. Images of the brain of a 21-year-old male who presented with subarachnoid hemorrhage associated with an intramedullary arteriovenous malformation. The AVM was treated in multiple staged sessions with n-butylcyanoacrylate. (A) Computed tomographic image without contrast shows extensive SAH. (B) T1-weighted MRI without contrast shows flow voids within the AVM nidus located at the craniocervical junction (arrows). (C) Gradient echo T2-weighted axial MRI shows the extensive involvement of the anterior and central aspects of the spinal cord and an enlarged anterior median vein with flow void.

Flow Void Veins Mri Exam
d
Vertebral Artery Flow Void

Figure 16.3. Continued. (D-F) Vertebral artery injection in the lateral and anterior-posterior projection shows the extent of the intramedullary AVM, with early drainage of the lower parts of the nidus through the enlarged anterior median vein (D, arrow). (E) Late arterial phase shows both enlarged veins of the middle cerebellar peduncle draining via the superior petrosal vein into the superior petrosal sinus (F, black arrow) and the dilated median anterior pontomesencephalic vein (F, open arrow).

Figure 16.3. Continued. (D-F) Vertebral artery injection in the lateral and anterior-posterior projection shows the extent of the intramedullary AVM, with early drainage of the lower parts of the nidus through the enlarged anterior median vein (D, arrow). (E) Late arterial phase shows both enlarged veins of the middle cerebellar peduncle draining via the superior petrosal vein into the superior petrosal sinus (F, black arrow) and the dilated median anterior pontomesencephalic vein (F, open arrow).

(Continued)

Anterior Pontomesencephalic Vein Vertebral Body

Figure 16.3. Continued. (D-F) Vertebral artery injection in lateral and anterior-posterior projection: (G) Superselective injection of the anterior spinal artery (open arrow) through a flow-guided micro-catheter, which has been placed over a guide wire (straight black arrow). Multiple sulcocommissural arteries are feeding the AVM nidus (curved arrow). A few of them have already been embolized with acrylate (see subtraction artifact).

Figure 16.3. Continued. (D-F) Vertebral artery injection in lateral and anterior-posterior projection: (G) Superselective injection of the anterior spinal artery (open arrow) through a flow-guided micro-catheter, which has been placed over a guide wire (straight black arrow). Multiple sulcocommissural arteries are feeding the AVM nidus (curved arrow). A few of them have already been embolized with acrylate (see subtraction artifact).

Vertebral Body

Figure 16.3. Continued. (H) Superselective injection of a subcommissural artery (thin arrow) shows a compartment of the intramedullary AVM that drains into the enlarged anterior median vein (thick arrow) cranially the vein of middle cere-bellar peduncle. The caudal drainage occurs through the anterior median vein (small arrow). (I,J) A staged embolization with complete AVM obliteration was achieved. Note the caliber reduction of the anterior spinal artery because of the shunt reduction. Note the displacement of the anterior spinal artery (J, curved arrow).

Anterior Spinal Artery

j h j complex venous drainage. The lesions are composed of multiple direct arteriovenous shunts with feeders from the ventral spinal axis (ASA) and dorsolateral pial network (PSAs), with glomus-type niduses that are usually extramedullary (pial) but can occasionally be intramedullary.1 The lesions are always located in the conus medullaris and cauda equina and can extend along the filum terminale all the way down.1 Symptoms can be caused by venous hypertension, venous compression of the cord/cauda equina, or hemorrhage. Unique to this type of spinal vascular malformation is frequent production of radiculopathy in addition to myelopathy.1

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