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Abstract
Spinal vascular malformations (SVMs) are an uncommon, heterogeneous group of vascular anomalies that can render devastating neurological consequences if they are not diagnosed and treated in a timely fashion. Imaging SVMs has always presented a formidable challenge because their clinical and imaging presentations resemble those of neoplasms, demyelination diseases, and infection. Advancements in noninvasive imaging modalities (MR and CT angiography) have increased during the last decade and have improved the ability to accurately diagnose spinal vascular anomalies. In addition, intraoperative imaging techniques have been developed that aid in the intraoperative assessment before, during, and after resection of these lesions with minimal and/or optimal use of spinal digital subtraction angiography. In this report, the authors review recent advancements in the imaging of SVMs that will likely lead to more timely diagnoses and treatment while reducing procedural risk exposure to the patients who harbor these uncommon spinal lesions.
Introduction
Spinal vascular malformations are an uncommon, heterogeneous group of vascular anomalies that can render devastating neurological consequences if they are not diagnosed and treated in a timely fashion. The most common classification system separates SVMs into the following 4 types: spinal DAVFs (Type I), intramedullary glomus malformations (Type II), extensive juvenile or metameric malformations (Type III), and perimedullary spinal cord AVFs (Type IV). However, Kim and Spetzler recently proposed a new classification system based on the anatomical description of SVMs, namely, extradural, intradural dorsal/ventral, intraduralintramedullary, extradural-intradural, and conus medullaris vascular malformations. Pathophysiologically, the shunting of arterial blood through dorsal and/or medullary veins can lead to either vascular steal, particularly from high-flow lesions, or venous hypertension and congestion, reducing intramedullary blood flow; both processes often lead to spinal cord ischemia and dysfunction. Timely diagnosis and a precise understanding of the angioarchitecture of these lesions can open therapeutic corridors and determine treatment strategies.
Imaging of SVMs has always presented a formidable challenge because their clinical and imaging presentations are similar to neoplasms, demyelination diseases, and infection. The gold standard of imaging of SVMs has traditionally been catheter-based 2D angiography because of its ability to produce images with superior temporal and spatial resolution. However, spinal 2D DS angiography is not without risks. Selective catheterization of arteries supplying an SVM can often be time consuming, require multiple catheterizations, involve long radiation exposure times, and use large volumes of potentially nephrotoxic contrast agents. Furthermore, selective catheterization of segmental arteries can lead to spinal cord infarction due to their embolization or occlusion. Therefore, advancements in noninvasive imaging modalities (MR and CT angiography) have increased during the last decade and have improved the ability to accurately diagnose spinal vascular anomalies. In addition, intraoperative imaging techniques have been developed that aid in the intraoperative assessment before, during, and after resection of these lesions with minimal and/or optimal use of spinal DS angiography.
The purpose of this report was to review recent advancements in the imaging of SVMs that will likely lead to more timely diagnoses and treatment while reducing procedural risk exposure to the patients who harbor these uncommon spinal lesions.
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