Spinal Vascular Lesions

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Spinal Vascular Lesions Spinal Vascular Lesions Spinal cord infarction Hemangioblastoma Cavernous malformation Vascular malformations (Type 1-4) Spinal artery aneurysm Troy Hutchins, MD Assistant Professor of Radiology Neuroradiology Section University of Utah Spinal Cord Arterial Supply Spinal Cord Arterial Supply anterior spinal artery anterior spinal artery posterior spinal arteries posterior spinal arteries Abrupt onset pain, weakness, loss of sensation Distal ½ thoracic cord often affected (arterial border zone, commonly due to aortic pathology Cervical cord: vertebral artery injury, thrombus Abrupt onset pain, weakness, loss of sensation Distal ½ thoracic cord often affected (arterial border zone), commonly due to aortic pathology Cervical cord: vertebral artery injury, thrombus 1

Acute: T2 hyperintense, mild expansion, DTI positive, central grey matter Chronic: central myelomalacia with owl s eye appearance AX DTI SAG STIR SAG DTI AX DTI AX T1FS+C AX T1 SAG T1FS+C 2

SAG DTI SAG T1FS+C : Ddx Ddx: Transverse Myelitis Transverse myelitis Viral myelitis/adem Multiple sclerosis Neuromyelitis optica Type 1 dural AVF : Kevin R. Moore, MD Ddx: Multiple Sclerosis Ddx: Neuromyelitis Optica SAG FLAIR AX T1FS+C SAG T1+C, Miral D. Jhaveri, MD 3

Hemangioblastoma Hemangioblastoma Subpial, posterior cord, enhancing nodule, syrinx/edema, flow voids in larger lesions (>2.5 cm) Approx. 2/3 sporadic, 1/3 VHL Subpial, posterior cord, enhancing nodule, syrinx/edema, flow voids in larger lesions (>2.5 cm) Approx. 2/3 sporadic, 1/3 VHL Hemangioblastoma Hemangioblastoma: Ddx Arteriovenous malformation Cavernous malformation Intramedullary neoplasm: ependymoma, astrocytoma, metastases AX T1+C SAG T1+C Cavernous Malformation Cavernous Malformation Low-flow lesions, dysplastic capillaries forming cavernous sinusoids Lobulated mulberry appearance Blood products of different ages Bloom on GRE Edema if recent hemorrhage SAG T1 SAG GRE 4

Cavernous Malformation Cavernous Malformation: Ddx Intramedullary neoplasm: ependymoma, astrocytoma, hemangioblastoma, metastases Arteriovenous malformation AX GRE Spinal Cord Vascular Malformations Spinal Cord Vascular Malformations Type 1: Spinal dural AVF Type 3: Juvenile AVM Type 4: Pial AVF Spinal dural fistulas: Type 1 Intradural pathology: Types 2-4 Direct communication radiculomeningeal artery to radicular vein Most common spinal vascular malformation (70%) Acquired: 40% posttraumatic, 60% spontaneous 85% single arterial feeder Direct communication radiculomeningeal artery to radicular vein Most common spinal vascular malformation (70%) Acquired: 40% posttraumatic, 60% spontaneous 85% single arterial feeder 5

Spinal Type 1: Spinal Dural AVF Bilateral arterial injections: Intercostal Lumbar Median and lateral sacral Vertebral Ascending cervical If no fistula found, also: Ascending pharyngeal Mengohypophyseal trunk Middle meningeal Occipital AX CTA COR CTA Lai PH et al. Multi-detector row computed tomography angiography in diagnosing spinal dural arteriovenous fistula: initial experience. Stroke. 2005 Jul;36(7):1562-4 Type 1: Spinal Dural AVF AX CISS COR CISS MRA Backes WH, Nijenhuis RJ. Advances in spinal cord MR angiography. AJNR Am J Neuroradiol. 2008 Apr;29(4):619-31. 6

Compact intramedullary nidus, multiple ASA +/- PSA feeders 2 nd most common (20%) Cervicothoracic Younger patients, acute deterioration, hemorrhage AX CTA SAG CTA SAG T1+C MRA AX GRE 7

Type 3: Juvenile AVM Extensive with multiple feeders, intra and extramedullary components Metameric Children, young adults Type 3: Juvenile AVM Type 3: Juvenile AVM Niimi Y, Uchiyama N, Elijovich L, Berenstein A. Spinal arteriovenous metameric syndrome: clinical manifestations and endovascular management. AJNR Am J Neuroradiol. 2013 Feb;34(2):457-63. doi: 10.3174/ajnr.A3212. PubMed PMID: 22859288. Niimi Y, Uchiyama N, Elijovich L, Berenstein A. Spinal arteriovenous metameric syndrome: clinical manifestations and endovascular management. AJNR Am J Neuroradiol. 2013 Feb;34(2):457-63. doi: 10.3174/ajnr.A3212. PubMed PMID: 22859288. Type 4: Pial AVF Type 4: Pial AVF Intradural perimedullary AVF with direct communication between spinal artery and vein 3 rd to 6 th decade COR T1+C COR T1+C 8

Type 4: Pial AVF Type 4: Pial AVF MRA CTA Type 4: Pial AVF Spinal Artery Aneurysm Rare cause of spinal SAH Usually fusiform and small (<3mm) Can be associated with vasculitis and noninflammatory vasculopathies Can spontaneously regress Spinal Artery Aneurysm Spinal Artery Aneurysm AX CT SAG T1 9

Spinal Artery Aneurysm Spinal Vascular Lesions: Summary DYNA CT Spinal cord infarction Hemangioblastoma Cavernous malformation Vascular malformations (Type 1-4) Spinal artery aneurysm Thank you 10

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