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Abstract
Background Intracranial dural arteriovenous (AV) fistula classifications focus on presence/absence of retrograde flow in the cortical veins of the brain as this angiographic finding portends a worse prognosis. However, prior categorization systems of AV shunts in the spine do not incorporate these features. We propose an updated classification for spinal shunting lesions that terms any shunting lesion with retrograde flow in any cortical vein of the brain or spinal cord medullary vein as “high risk”. To present this classification, we analyzed our center’s most recent experience with cervical spine shunting lesions.
Methods The electronic medical record at our institution was reviewed to identify shunting lesions of the cervical spine and patient demographics/presentation. Comprehensive craniospinal digital subtraction angiograms were evaluated to classify shunt location, type (arteriovenous malformation (AVM) vs arteriovenous fistula (AVF)), and presence of high-risk venous drainage.
Results Some 52 lesions were identified and categorized as pial/dural/epidural/paravertebral AVFs and intramedullary/extraspinal AVMs. Lesions were classified as high risk or not depending on the presence of retrograde flow into at least one vein that directly drains the spinal cord or brain. All patients who presented with either hemorrhage or infarct had underlying high-risk lesions. Additionally, 50% (17/34) of symptomatic patients with high-risk lesions presented with neurological extremity symptoms (OR=10.0, p=0.037) most of which fit a myelopathic pattern.
Conclusion We present an updated classification system for shunting lesions of the spine that focuses on high-risk retrograde flow to the brain or spine in addition to anatomical location in order to better inform patient management.
- Fistula
- Arteriovenous Malformation
- Angiography
- Cervical
- Spine
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Footnotes
X @Misikbay, @traviscaton, @RaghavMattay, @WoodyHan2, @mattamansMD
Contributors All authors were responsible for the design of this work. MI and MTC were responsible for the initial study design, and MI performed all the initial data collection. MI, MTC, KHN, SWH, and MRA were involved in the primary analysis of the collected data. All authors were involved in the final interpretation of the analyzed data, with the most time being spent on this by MI and MRA. MI, MTC, and MRA were responsible for creating the initial draft of this manuscript, with the rest of the authors contributing to its revision significantly. MI and MRA worked primarily on incorporating all the changes All authors approved the final version that is to be published. All authors have agreed to be accountable for all aspects of the work. MRA is the gurantor for this work.
Funding The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health (NIH). MRA: consultant for Stryker Neurovascular, Microvention, Medtronic, VS3 Medical; founder, board member and shareholder for VS3 Medical; founder, board member, and shareholder for VDF Industries. DMSR: consultant for Phenox, Penumbra, Q'Apel, Rapid Medical. KHN: consultant for Stryker Neurovascular, Imperative Care, Boston Scientific. SWH: research support from NIH (R01CA194533, R42CA265316, R01EB012031); consultant for Medtronic, Imperative, Cerenovus; ownership interest in Filtro. UCSF has contract and grant support from Siemens, Stryker Neurovascular, and Route 92.
Disclaimer Research reported in this publication was supported by Peer Reviewed Medical Research Program of the Department of Defense under award number PR201091, and the T32 Training Grant from the National Institute of Biomedical Imaging and Bioengineering of the National Institute of Health under award number T32EB001631.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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