Concomitant spinal dural arteriovenous fistula and nodular fasciitis in an adolescent: case report

Background Spinal dural arteriovenous fistula (SDAVF) usually occurs during the 4th to 6th decades of life, and adolescent SDAVF is rarely reported. SDAVF arising around a tumor is also rare, and reported tumors are mostly schwannoma and lipoma. Case presentation We reported a 16-year-old male presented with progressive weakness and numbness of lower limbs for 3 months. A SDAVF was found, which was fed by right radicular arteries from segmental artery at L2 level and drained retrogradely into perimedullary veins. A concomitant spinal extradural nodular fasciitis at right L1/L2 intervertebral foramen was also noted. The SDAVF was completely obliterated by endovascular treatment and the tumor was debulked. The patient recovered well after the procedures. Conclusions Our case report suggests SDAVF can occur in adolescent. The concomitant presence with a nodular fasciitis indicates that although it usually arises in subcutaneous tissue but can rarely form on the dura of spine.

Intraoperative Spinal Angiography during Microsurgical Occlusion of Spinal Dural Arteriovenous Fistula within the Hybrid Operation Room

Background Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy in predominantly middle-aged men. Treatment modalities include surgical obliteration and endovascular embolization. In surgically treated cases, failure of obliteration is reported in up to 5%. The aim of this technical note is to present a safe procedure with complete SDAVF occlusion, verified by intraoperative digital subtraction angiography (DSA). Methods We describe four patients with progressive leg weakness who underwent surgical obliteration of SDAVF with spinal intraoperative DSA in the prone position after cannulation of the popliteal artery. All surgeries took place in our hybrid operating room (OR) and were accompanied by electrophysiologic monitoring. Surgeries and cannulation of the popliteal artery were performed in the prone position. Ultrasound was used to guide the popliteal artery puncture. A 5-Fr sheath was inserted and the fistula was displayed using a 5-Fr spinal catheter. Spinal intraoperative DSA was performed prior to and after temporary clipping of the fistula point as well after the final SDAVF occlusion. Results The main feeder of the SDAVF fistula in the first patient arose from the right T11 segmental artery, which also supplied the artery of Adamkiewicz. The second patient initially underwent endovascular treatment and deteriorated 5 months later due to recanalization of the SDAVF via a small branch of the T12 segmental artery. The third and fourth cases were primarily scheduled for surgical occlusion. Access through the popliteal artery for spinal intraoperative DSA proved to be beneficial and safe in the hybrid OR setting, allowing the sheath to be left in place during the procedure. During exposure and after temporary and permanent occlusion of the fistulous point, intraoperative indocyanine green (ICG) video angiography was also performed. In one case, the addition of intraoperative DSA showed failure of fistula occlusion, which was not visible with ICG angiography, leading to repositioning of the clip. Complete fistula occlusion was documented in all cases. Conclusion Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.

Isolated acute renal infarction in an obese patient

Background: Uncontrolled cardiovascular (CV) risk factors is been related to a higher incidence of atherosclerosis. Obesity itself could predispose to significant cardiac disease including arterial atheromatous leading to acute events. Case: A 46 years old obese patient who presented with left abdominal pain radiating to the left quadrant and left testicle. No significant abnormality was observed in the laboratories, but imaging showed left renal lower pole may be due to renal infarct (Figure 1), and CT-Angiography (CTA) of the abdomen showed infarction of the anterior two-thirds of the lower pole of the left kidney (Figure 2) secondary to occlusion of the supplying small inferior segmental artery and minimal atherosclerosis. Transthoracic Echocardiogram (TTE) showed a density in the LVOT may be artifact vs. calcification (Figure 3). A transesophageal echocardiogram (TEE) showed Grade III atherosclerotic changes of descending aorta (Figure 4), aortic arch, and a mobile plaque seen in the thoracic aorta. Conclusion: Cardiovascular risk factors have been associated with multiple vascular complications. Obesity as a single cardiovascular risk factor is associated with advanced arterial disease; our case is an example of an unstable atheromatous lesion causing thrombosis and ischemia in the kidney in a patient without another risk factor for thrombosis.

Veno-Arterial Index (VAI)—A Promising Tool For Identifying Renal Transplant Rejection

The objective of this study is to evaluate the veno-arterial index (VAI) as a predictor of renal rejection in kidney transplant patients. A diagnostic test study was conducted between January 2014 and May 2018. Renal transplant patients who underwent percutaneous renal biopsy were included. The VAI was obtained by measuring the flow velocity in the renal segmental vein and dividing this value by the peak systolic velocity of the segmental artery in this same location. The records of 77 patients were analyzed. Among these patients, 32 (42%) were positive for transplant rejection and 29 presented with acute rejection. In patients with renal rejection, the median VAI was 0.67 (interquartile range [IQR] = 0.56-0.87), and in kidneys with a negative biopsy for rejection, the median VAI was 0.41 (IQR = 0.27-0.57), with a statistically significant difference ( P = .007) and a value much higher than that obtained for the general population of 0.30 (IQR = 0.18-0.44). Subacute and acute rejected kidneys had an even higher VAI of 0.725 (IQR = 0.57-0.87; P = .0001). Although the resistive index has a good correlation with glomerular filtration, it is not possible by that index to differentiate among the multiple causes that can lead to graft dysfunction. The results of this study show that the VAI might be a useful parameter, which when elevated could predict renal transplant rejection.

Complex, Isolated Pulmonary Arteriovenous Malformation in Two Children With Severe Cyanosis.

We present two cases of Isolated complex pulmonary arteriovenous malformations in two children presenting with cyanosis and exercise intolerance. We present the anatomical features and the management of each case. One patient was treated with surgical ligation of the draining vein, and one patient was treated percutaneously by closure of the feeding segmental artery.

Pulmonary Arteriovenous Malformation in Combination With Stroke.

BackgroundAs pulmonary arteriovenous malformation (PAVM) include a right-to-left shunt, it can be accompanied by fatal complications such as stroke and brain abscess due to paradoxical embolism. There are few PAVM patients accompanied by concurrent pulmonary embolism, so the treatment sequence has not been established. Case presentationA 62-year-old female patient was transferred to our hospital with a simple PAVM and concurrent bilateral pulmonary embolism (PE). The acute thromboembolus was extended to the proximal segmental artery where the feeding artery originated. Anticoagulation was started, but on the fifth day of admission, the patient complained of left side weakness and brain magnetic resonance imaging revealed an acute infarction in the right lateral thalamus. This situation could lead to a dilemma between the risk of thrombus migration during catheter manipulation in PAVM embolization and another embolic event due to the late occlusion of the shunt during anticoagulation. This complex situation was successfully managed with delayed endovascular embolization for PAVM after four months of anticoagulation. The cause of PE in this patient was eventually diagnosed as antiphospholipid syndrome (APS).ConclusionThe authors reported a rare case of APS-induced PE in the PAVM feeding artery course that led to stroke during hospitalization. We successfully treated this patient with delayed endovascular embolization for PAVM after anticoagulation for PE and stroke. It is thought to be valuable in deciding for a treatment plan for this rare condition.

Abstract 1122‐000013: Spinal Dural Arterio‐Venous Fistula: A Masquerade as a Longitudinal Myelitis

Introduction : SDAVF are rare and frequently misdiagnosed due to their nonspecific symptomatology and delay of presentation on imaging. Spinal digital subtraction angiogram is the gold standard diagnostic test. Delayed diagnosis and treatment of SDAVF can lead to irreversible neurologic damage. Methods : None Results : Two female patients, 69 and 74 years old, each developed recurrent episodes of subacute worsening myelopathy and urinary retention. The subacute onset of symptoms and longitudinal appearance on cord imaging raised concern for inflammatory myelitis. Despite a negative CSF analysis, and the absence of serum inflammatory, metabolic and infectious markers, the working diagnosis was seronegative neuromyelitis optica spectrum disorder. In accordance, both patients were treated with plasma exchange and IV rituximab, initially displaying stabilization on imaging. However, further worsening and extension of the myelopathy alongside the presence of flow voids in one patient’s repeat MRI nine months post‐presentation raised the question of an alternate etiology. A spinal angiogram was ordered for the patient, revealing SDAVF. Subsequently, the patient underwent complete Onyx embolization of the right L2 feeder and surgical clipping of the right L1 feeder. This resulted in stabilization and improvement of symptoms. Although the second patient did not display flow voids in their MRI, they were ordered a spinal angiogram due to their similar clinical course, indeed confirming SDAVF. The patient underwent successful complete embolization of the L3 segmental artery on the right resulting in improvement of symptoms. Conclusions : Clinicians should have a high index of suspicion for SDAVF when a patient presents with a longitudinally extensive transverse myelitis negative for inflammatory markers and is unresponsive to treatment. While the appearance of flow voids on imaging is a helpful diagnostic feature, these may not be present in patients.

Abstract 1122‐000236: Intravascular Delivery and Crosslinking of Photosensitive Hydrogels for Embolizing Animal Models of AVMs and Tumors

Introduction : Embolization represents a minimally invasive treatment modality for arteriovenous malformations (AVMs), tumors, and other indications, but can be limited by currently available embolic agents, in terms of safety and efficacy. Discovery of new and improved agents could lead to better treatment outcomes. The goal of this project was to test a novel embolization methodology for the treatment of AVMs and tumors. Methods : We formulated low‐viscosity, shear‐thinning hydrogel formulations which were mixed with a photo‐initator agent and non‐ionic contrast medium. We then developed a method of intravascular hydrogel delivery with photo crosslinking at the tip of the catheter, using an integrated optical fibre. This allowed for rapid transition from a low viscosity liquid to a crosslinked solid‐state hydrogel to block blood flow to the vascular target. In addition, the UV intensity can be dynamically modulated, in real‐time, to modify the degree of crosslinking and thus the viscosity of the embolic agent. We utilized the swine rete mirabile as an animal model for AVMs, and the swine renal arterial tree (inferior segmental artery) as a model for hypervascular tumors. 5 animals were utilized without prior preparation. Embolization was graded based on degree of complete obliteration of the rete nidus or the renal arterial tree. Any non‐target embolization or other complications were recorded. Follow‐up angiography was performed at the 4‐week interval. Results : With a combination of shear‐thinning properties and dynamic modulation of photo crosslinking, we show that we are able to deliver an embolic agent with a viscosity range of up to 10^4 Pa*s through a single low viscosity precursor that is injectable through microcatheters (Figure 1). Using this methodology, hydrogel embolization was technically successful in all animals. Following embolization, 4/5 rete mirabile and 5/5 inferior renal arterial trees were completely obliterated. Representative angiographic images are shown in Figures 2 and 3. There were no instances of clinical or angiographic complications. Conclusions : We demonstrated a novel method of intravascular delivery of low viscosity photosensitive hydrogels, with photo crosslinking at the tip of the catheter, to successfully embolize animal models for AVMs and tumors. This promising technology will be investigated further with longer‐term comparative animal trials.

Comparison of Renal Segmental Artery Blood Flow on Doppler in Young Obese & Non Obese Individuals

Aim: To compare renal segmental artery blood flow on Doppler in young obese & non-obese individuals. Methodology: In University Ultrasound Clinic Green Town, Lahore, Pakistan, a comparative study was conducted. 180 patients of age group 16 to 25 were enrolled in this study with convenient sampling technique. All the obese & non-obese patients having no history of renal disease were included in this study. Hypertensive and diabetic patients were also included. Pregnant females having any renal parenchymal disease were excluded. Results: In 90 non-obese individuals the average mean of PI was .989±.249 while in 90 obese individuals the average mean of PI was .985±.338. No statistical difference between the two averages as p-value 0.928> α=0.05. Conclusion: Study concluded that no statistically significant difference between the average PI in non-obese individuals compared to the average of PI in obese individuals. Keywords: Obese, Renal segmental artery, Pulsatility Index (PI), Ultrasonography

Association Between Vertebral Segmental Artery Occlusion and Kummell Disease: A Prospective Cohort Study Based On MRA

Purpose We designed a prospective cohort study based on magnetic resonance angiography (MRA) to identify whether the degree of Kummell disease (KD) vertebral artery occlusion is more severe than that of simple vertebral compression fractures. Methods We enrolled elderly patients with VCFs who met the established criteria from January 2019. MRA was used to determine the degree of vertebral artery occlusion. We defined the lesion segmental occlusion rate (LSOR) as the sum of the ischemic values of the bilateral vertebral segmental arteries (0 means expedite, 1 means stenosis, 2 means occlusion; range from 0–4). The average LSOR is the sum of LSORs divided by the number of vertebrae. Follow-up outcomes included VAS and ODI scores after surgery. X-rays were re-examined at 1 year after surgery to determine whether the vertebral body had recollapsed. Results 25 cases of KD segments and 37 cases of non-KD segments were included. The average LSOR in KD segments was significantly higher than that in non-KD segments (1.44 vs 0.32, P<0.01). The recollapse rate of the KD segments after one year was significantly higher than that in non-KD segments (56% vs 27%, P=0.03). In non-KD segments, 57.1% of segments with a high LSOR (1–2) recollapsed, and 20% of segments with a low LSOR (0) recollapsed (P=0.045) Conclusions The degree of artery occlusion in the KD segment is more serious than that in the non-KD segment. KD segments or non-KD segments with a high degree of artery occlusion will have a higher recollapse rate.