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British Journal of Neurosurgery Dec 2023Sacral dural arteriovenous fistulas (DAVFs) with bilateral arterial supplies are extremely rare. To date, only two cases with arterial supply from bilateral lateral... (Review)
Review
Sacral dural arteriovenous fistulas (DAVFs) with bilateral arterial supplies are extremely rare. To date, only two cases with arterial supply from bilateral lateral sacral arteries (LSAs) were reported. We report a rare case of sacral DAVF with arterial supply from bilateral LSAs. A 56-year-old man presented with a 2-month history of progressive weakness and numbness in his lower extremities, along with urinary incontinence. Spinal magnetic resonance imaging (MRI) showed extensive edema of the spinal cord, vascular flow voids, and intraparenchymal enhancement. Spinal angiography revealed a spinal DAVF at the level of S1 supplied by bilateral LSAs and drained ascending into the perimedullary venous plexus. The fistula was successfully treated with endovascular embolization. Sacral DAVFs present various diagnostic and treatment difficulties because of the complex angioarchitecture. Successful management of these lesions requires a profound understanding of the variable patterns of arterial supply in this region.
Topics: Male; Humans; Middle Aged; Spinal Cord; Angiography; Magnetic Resonance Imaging; Arteries; Central Nervous System Vascular Malformations
PubMed: 33983105
DOI: 10.1080/02688697.2021.1916434 -
Clinical Neurology and Neurosurgery Nov 2021A sacral dural arteriovenous fistula (dAVF) is extremely rare, and the pathophysiological and clinical features have not been established. A 70-year-old man developed...
A sacral dural arteriovenous fistula (dAVF) is extremely rare, and the pathophysiological and clinical features have not been established. A 70-year-old man developed gradually progressive right-dominant bilateral sensory disorder of the lower limbs. His clinical course and electrophysiological findings were similar to those of multiple mononeuropathy. However, angiography showed a sacral dAVF at the right intervertebral foramen between the fifth lumbar and first sacral vertebrae. Endovascular embolization of the dAVF improved his clinical symptoms and electrophysiological findings. A sacral dAVF can mimic multiple mononeuropathy in terms of its clinical features and electrophysiological findings. A sacral dAVF is a treatable disease and should be considered as a differential diagnosis of lower extremity disorders.
Topics: Aged; Central Nervous System Vascular Malformations; Diagnosis, Differential; Endovascular Procedures; Evoked Potentials, Somatosensory; Follow-Up Studies; Humans; Male; Mononeuropathies; Neural Conduction; Sacrum
PubMed: 34739881
DOI: 10.1016/j.clineuro.2021.106993 -
World Neurosurgery Nov 2020The occurrence of sacral dural arteriovenous fistula (dAVF) is rare. The detailed vascular architecture of sacral dAVF, including 3-dimensional (3D) angiographic images... (Review)
Review
BACKGROUND
The occurrence of sacral dural arteriovenous fistula (dAVF) is rare. The detailed vascular architecture of sacral dAVF, including 3-dimensional (3D) angiographic images with operative findings, has not been evaluated compared with that of the thoracic and lumbar levels. We report a case of sacral dAVF with 3D angiographic examination and operative findings, with a literature review.
CASE DESCRIPTION
A 60-year-old man presented with progressive urinary incontinence and gait disturbance. A sacral dAVF was detected at the S1-2 level. The shunt point was at the medial side of the line between the intermediate sacral crest and the most medial point of the L5 pedicle circle at the anterior posterior view of the angiography; we defined this type as the medial type. After embolization, latent inflow arteries were visualized ipsilaterally and contralaterally. During surgery, because of dAVF recurrence, a vascular tangle was found on the dura. The surgical interruption of the draining vein improved the patient's symptoms. From the literature review, 92% of cases had medial-type shunt point. It is possible for sacral dAVF to have multiple inflow arteries originating ipsilaterally or bilaterally, and a venous pouch.
CONCLUSIONS
The shunt point of sacral dAVF tended to be located medially, not in the sacral foramen. Sacral dAVF has unique angioarchitecture. The differentiation of dAVF from epidural arteriovenous fistula may not be easy in some cases of sacral lesions. Therefore, further studies with a larger number of patients focused on the detailed vascular architecture are needed.
Topics: Angiography; Central Nervous System Vascular Malformations; Embolization, Therapeutic; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Sacrum; Spinal Cord
PubMed: 32068174
DOI: 10.1016/j.wneu.2020.02.037 -
World Neurosurgery Jan 2020Spinal dural arteriovenous fistulas (DAVFs) in the sacral region are extremely rare. The location and complex angioarchitecture of these lesions make both identification...
BACKGROUND
Spinal dural arteriovenous fistulas (DAVFs) in the sacral region are extremely rare. The location and complex angioarchitecture of these lesions make both identification and treatment challenging, even in experienced hands. We report on a sacral DAVF with a unique angioarchitecture and discuss its specific anatomy.
CASE DESCRIPTION
A 76-year-old male presented with progressive distal paraparesis and spinal ataxia. Three lumbar decompression surgeries were performed between 2016 and 2018 elsewhere on the basis of suspected degenerative lumbar syndrome. On admission to our center, the patient was wheelchair dependent due to extensive spinal ataxia associated with bilateral foot paresis and hypoesthesia. Spinal contrast-enhanced time-resolved magnetic resonance angiography and digital subtraction angiography were performed after admission to our center. Contrast-enhanced magnetic resonance angiography examinations suggested a sacral DAVF. Subsequent digital subtraction angiography demonstrated a spinal DAVF on the left side at the S2 vertebral level supplied via an arterial epidural branch from the right L4 segmental artery. The fistula was treated via surgical interruption of the proximal part of the radicular drainage vein.
CONCLUSIONS
Sacral DAVFs present serious diagnostic difficulties and require a profound understanding of possible fistula-supplying arteries of the sacral region. Microsurgical interruption of the often ventrally located drainage vein presents an efficient treatment modality and could provide an immediate confirmation of fistula occlusion using indocyanine green videoangiography.
Topics: Aged; Angiography, Digital Subtraction; Central Nervous System Vascular Malformations; Decompression, Surgical; Humans; Magnetic Resonance Angiography; Male; Sacrum
PubMed: 31550539
DOI: 10.1016/j.wneu.2019.09.078 -
World Neurosurgery Sep 2020Spinal dural arteriovenous fistulas (DAVFs) and spinal arteriovenous malformations (AVMs) are relatively rare. Moreover, multiple spinal cord vascular lesions in an... (Review)
Review
BACKGROUND
Spinal dural arteriovenous fistulas (DAVFs) and spinal arteriovenous malformations (AVMs) are relatively rare. Moreover, multiple spinal cord vascular lesions in an individual, such as double DAVFs and DAVF with AVM, are extremely rare. To date, there are only several reported cases of concomitant spinal DAVFs and AVMs.
CASE DESCRIPTION
A 25-year-old woman presented with pain of the right lower limb persisting for 1 month. Spinal magnetic resonance imaging showed prominent signal flow voids in the lumbosacral canal. Spinal digital subtraction angiography (DSA) showed a sacral DAVF fed by the right lateral sacral artery and a spinal intradural AVM at the conus medullaris fed by the anterior spinal artery from the left T11 intercostal artery. The drainage veins in these 2 lesions were respective and without common anastomosis. The diagnosis of concomitant sacral DAVF and conus AVM was made. Microsurgery was performed to excise these lesions successfully in the same operation. The patient's symptoms gradually improved after surgery. Postoperative spinal DSA confirmed the complete disappearance of the 2 lesions.
CONCLUSIONS
The concomitant presence of sacral DAVF and conus AVM is extremely rare. Nonetheless, clinicians should be aware of the possibility of the coexistence of multiple types of spinal vascular lesions in a single patient.
Topics: Adult; Arteriovenous Fistula; Arteriovenous Malformations; Central Nervous System Vascular Malformations; Female; Humans; Spinal Cord; Spinal Cord Diseases; Vertebral Artery
PubMed: 32535050
DOI: 10.1016/j.wneu.2020.06.022 -
Surgical Neurology International 2023Sacral dural arteriovenous fistulas (AVFs) are often undiagnosed at the initial presentation due to their rarity.
BACKGROUND
Sacral dural arteriovenous fistulas (AVFs) are often undiagnosed at the initial presentation due to their rarity.
CASE DESCRIPTION
For 1 year, a 71-year-old man developed progressive motor and sensory disturbances in both legs. Magnetic resonance imaging showed spinal cord edema with mild contrast enhancement at the T9-10 and T12 levels. Although mild venous dilatation was observed only at the cauda equina level, it was not initially recognized as abnormal. Blood and cerebrospinal fluid tests and spinal angiography of the lower thoracic to upper lumbar levels were nonspecific. The patient was unsuccessfully treated with three courses of high-dose intravenous methylprednisolone. Ultimately, following repeat spinal angiography (i.e., including the bilateral internal iliac arteries) that revealed a low-flow sacral dural AVF supplied by the right lateral sacral artery, the patient underwent successful surgical venous AVF occlusion/transection.
CONCLUSION
In cases of spinal cord edema without perimedullary abnormal flow voids, careful spinal angiography including the sacral spine is necessary even if only minimal venous dilation is initially observed at the cauda equina level.
PubMed: 37680920
DOI: 10.25259/SNI_606_2023 -
World Neurosurgery Jun 2018Anterior sacral meningocele (ASM) leading to secondary rectothecal fistula is extremely rare, and to date only 5 such cases have been described in the world literature. (Review)
Review
BACKGROUND
Anterior sacral meningocele (ASM) leading to secondary rectothecal fistula is extremely rare, and to date only 5 such cases have been described in the world literature.
CASE DESCRIPTION
We describe an uncomplicated case of a 52-year-old female patient presenting with cerebrospinal fluid leak from the anus who was investigated and found to have an ASM with rectothecal fistula. The ASM and rectothecal fistula were subsequently repaired using a posterior approach. Pertinent literature review, clinical findings, neuroimaging, and surgical management are described for these rare lesions.
CONCLUSION
Early diagnosis and surgical disconnection of the fistulous tract led to satisfactory outcome in the present case and avoided the catastrophic complication of meningitis.
Topics: Anal Canal; Cerebrospinal Fluid Rhinorrhea; Digestive System Fistula; Female; Humans; Meningocele; Middle Aged; Sacrum
PubMed: 29572171
DOI: 10.1016/j.wneu.2018.03.087 -
Cureus Oct 2022Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia,... (Review)
Review
Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse.
PubMed: 36465795
DOI: 10.7759/cureus.30691 -
British Journal of Neurosurgery Jun 2024Sacral fractures are rare and either associated with high-energy trauma or osteoporosis in most cases. A search of the current literature on sacral fractures and... (Review)
Review
BACKGROUND
Sacral fractures are rare and either associated with high-energy trauma or osteoporosis in most cases. A search of the current literature on sacral fractures and cerebrospinal fluid fistula identified only few cases. Pathological fractures are uncommon and exceedingly rare in case of Tarlov cysts. Sacral fractures can be missed in oligosymptomatic patients. However, severe complications may emerge as shown by this case report.
METHODS
We present the case of a pathological sacral fracture at the level S2/3 following a low-impact trauma, associated with a Tarlov cyst, which was complicated by an anterior CSF fistula and intraventricular fat emboli.
RESULTS
The patient was treated conservatively with strict bedrest and a CT-guided blood patch. Postponed mobilization was successful with decreasing orthostatic symptoms. Follow-up MRI and CT imaging showed a complete resolution of the ventral CSF fistula and ossification of the fracture. The intraventricular fat did not resolve, however, there was no radiological sign of hydrocephalus with excellent clinical outcome at 6-months follow-up.
CONCLUSION
Although exceedingly rare, sacral Tarlov cysts may be associated with pathological fractures of the sacrum. Relevant complications can emerge and need to be properly addressed.
Topics: Female; Humans; Embolism, Fat; Fistula; Magnetic Resonance Imaging; Sacrum; Spinal Fractures; Tarlov Cysts; Tomography, X-Ray Computed; Aged
PubMed: 34397315
DOI: 10.1080/02688697.2021.1940848