Spontaneous spinal cerebrospinal fluid venous-fistula treated with transvenous embolization: A case report

Background: Spinal cerebrospinal fluid venous fistula (CVF) is a recognized cause of chronic positional headache and spontaneous intracranial hypotension (SIH). It occurs due to an aberrant connection formed between the spinal subarachnoid space and an adjacent spinal epidural vein. The diagnosis of CVF can be difficult to establish but can be documented utilizing advanced imaging techniques (e.g., enhanced MR myelography/digital subtraction myelography). Their treatment involves surgical ligation of the involved nerve root, imaging-guided epidural blood patching, and/or endovascular embolization. Here, we report a 40-year-old male who presented with a symptomatic lumbar CVF successfully treated with transvenous embolization. Case Description: A 40-year-old male presented with several months of positional headaches. The MRI of the brain showed diffuse pachymeningeal enhancement consistent with the diagnosis of SIH. Although the MR of the lumbar spine was unremarkable, the MR myelogram with digital subtraction imaging showed a CVF at the L2 level. Following transvenous embolization (i.e., through the Azygous vein), the patient’s symptoms fully resolved. Conclusion: Spinal CVF are rare and may cause chronic headaches and symptoms/signs of SIH. In this case, an MR myelogram with digital subtraction images demonstrated the anomalous connection between the spinal subarachnoid space and an adjacent spinal epidural vein at the L2 level. Although open surgical ablation of this connection may be feasible, less invasive techniques such as endovascular embolization should become the treatment of choice for the future management of CVF.

Quantification of Lumbar Spinal Canal Stenosis by Quantitative Fat-Suppressed Contrast-Enhanced Magnetic Resonance Imaging

Fat-suppressed T1-weighted magnetic resonance images (MRIs) enhanced with gadolinium can evaluate the internal vertebral venous plexus and cauda equina. This study compared such findings with clinical situations and discusses whether these are helpful for symptomatic grading and selection at the surgical level in patients with lumbar central stenosis. A total of 263 patients (337 levels < 75 mm2 of dural cross sectional area (DCSA)) were included. The enhancement patterns of dorsal epidural vein (DVCE), periradicular vein (PVCE) and intraradicular vein (IRCE) were assessed qualitatively. The quantification of IRCE was acquired by the ratio (%) (enhancement parameters: MS/P1, MS/P2, WR/P1, WR/P2) of signal intensities between the cauda equina (MS-IRCE: maximal spot rootlet, WR-IRCE: whole rootlets) and psoas muscle (P1, P2). Receiver-operator characteristic curves were plotted to obtain imaginary cutoff values for the prediction of symptomatic appearance or operation decision. All levels were classified into seven groups on the basis of pain distribution and the presence of IRCE. PVCE was significantly related to high incidences of symptoms, unilaterality and operation. DVCE and IRCE were connected with high incidences of symptoms, bilaterality and operation. IRCE was also related to high visual analogue scale (VAS), small DCSA and high enhancement parameters. The order of the group was concordant with the degree of enhancement parameters (p = 0.000). Cutoff values of enhancement parameters for prediction were as follows: symptoms (147/123/140/121), bilaterality (165/139/157/137) and operation (164/139/159/138). Enhancement patterns and parameters could help in stratification, grading and decision-making at the surgical level.

Cervical cord decompression following embolisation of a giant cervical vertebro-vertebral arteriovenous fistula

Arteriovenous fistulation between the vertebral arteries to extradural (epidural) veins, termed vertebro-vertebral arteriovenous fistulae, are uncommon diagnoses without established diagnostic algorithms or treatment options. Minimal evidence exists describing the management of this pathology. Endovascular treatment was performed under general anaesthesia by coil occlusion of the vertebral artery from the point of the fistula to the mid-vertebral artery. Repeat magnetic resonance angiographic imaging one week following the procedure confirmed an 80% reduction in the size of the epidural vein and decompression of the cervical spinal cord. At four-week follow-up there was significant qualitative improvement in the myelopathic symptoms including walking distance and pain. Normal physiological filling of the collapsed extradural vein was observed on follow-up digital subtraction angiography at five months. Catheter angiography by an experienced interventional neuro-radiologist is critical in defining the anatomy and providing minimally invasive treatment.

Epidural Venous Plexus Engorgement: What Lies Beneath?

Epidural venous plexus engorgement may occur due to several conditions that prevent the normal venous circulation. Inferior vena cava agenesis is a very rare cause of epidural venous enlargement. We present a case with a very thin inferior vena cava and left iliac vein agenesis who presented with back pain due to epidural vein engorgement and lacked other venous problems such as deep vein thrombosis.