Vascular Diseases Of The Spinal Cord

Investigation

MRI will demonstrate abnormal signal from the lesion or from draining veins. Myelography will also demonstrate abnormal draining veins. Selective angiography is required to delineate arterial feeders.

Coronal MRI showing dilated draining veins

Corresponding sagittal MRI showing lesion at C5/6 level

Management

Untreated, 50% of patients with gradual onset of symptoms would be unable to walk within 3 years. Treatment should prevent progression and may well improve a gait or bladder disturbance. Delay may result in irreversible cord damage.

Techniques: Embolisation - may successfully obliterate dural AVMs, particularly when fed by one or two dural arteries

- may aid subsequent operative treatment

- or may produce symptomatic improvement in inoperable lesions.

Surgery - It is important to identify and divide the feeding vessel and excise the shunr. Total excision of all the dilated veins is probably unnecessary and would increase the operative hazards. A decompressive laminectomy alone is of no benefit. Intramedullary AVMs and/or AVMs lying ventral to the cord cannot be excised.

Spinal Epidural and Subdural Haematomas: These may present with a rapid onset of paraplegia. Epidural or less commonly, subdural haematoma may occur due to rupture of a spinal AVM, after minor trauma or lumbar puncture, or spontaneously in patients with a bleeding disorder, liver disease or on anticoagulant therapy. MRI (or myelography) clearly demonstrates the lesion. Urgent decompression is required after correcting any coagulation deficit, without waiting for spinal angiography. Pathological examination of the haematoma may reveal angiomatous tissue; in other patients, there is no evident cause.

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