Spinal cord AVM and venous malformations

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  1. Most vascular malformations of the spine and spinal cord are AVMs or AV fistulas (AVFs); cavernous angiomas (occurring more commonly in females) and capillary telangiectasias (less common); venous angiomas rarely, if ever, are encountered
    1. capillary telangiectasias are most commonly found in the pons and in some cases are associated with Osler-Weber-Rendu syndrome
  2. AVMs
    1. type 1 – AVF (a true dural AVF); most common spinal cord AVM; predominantly found in the dorsal aspect of the lower thoracic cord and conus medullaris; most consist of a single transdural arterial feeder that drains into an intradural arterialized vein; affects mostly men in the 5th to 8th decade; 40% are due to trauma; progressive neurologic deterioration (probably due to venous hypertension) is typical; low flow and high pressure
    2. type 2 – glomus malformations are intramedullary AVMs in which a localized compact vascular plexus is supplied by multiple feeders from the anterior or posterior spinal arteries; drain into a tortuous venous plexus that surrounds the spinal cord; usually located dorsally at the cervicomedullary junction; most patients present with acute onset of symptoms secondary to intramedullary hemorrhage; high flow and high pressure
    3. type 3 – juvenile type; large, complex vascular masses that involve the cord and often have extramedullary or even extraspinal extension; often have feeders from multiple levels; high flow and high pressure
    4. type 4 – intradural extramedullary AVFs; fed by the anterior spinal artery and lie completely outside the spinal cord and pia mater; most are anterior to the spinal cord and are fed by the anterior spinal artery; symptoms are progressive in nature; low flow and high pressure or high flow and high pressure
      1. both anterior and posterior spinal arteries are branches from the vertebral artery
  3. spinal cord ischemia is usually most severe in the distribution of the anterior spinal artery because the posterior spinal artery is more a plexus of arteries with extensive anastomoses
    1. with a lesion of the spinal cord from ischemia or pressure, the spinothalamic tracts (pain and temperature and graphesthesia) are more vulnerable to injury than are the posterior columns (vibration, position) which are supplied by the posterior spinal arteries
    2. after spinal cord infarction, CSF protein may be slightly elevated
  4. Foix-Alajouanine syndrome is a subacute necrotizing myelitis that is apparently associated with spinal cord AVM’s due to congestion of draining veins
    1. Decompression sickness (a.k.a. the ‘bends’) can also cause a venous stasis and infarction of the spinal cord with symptoms of pain, paresthesia, weakness, sensory loss, and urinary dysfunction
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