Spinal vascular malformations and treatment

Abstract

Spinal vascular malformations are rare, but a diverse group of neurovascular pathologies including arteriovenous malformations (AVMs), cavernous malformations, and dural arteriovenous fistulas (dAVFs) that occur due to developmental derangement of the vascular system. Though classified variously, the commonly followed one is anatomic classification based on the morphology of the malformation to which added are cavernomas and spinal vascular tumors. Pathophysiologic mechanisms leading to clinical symptoms include intramedullary or subarachnoid hemorrhages, arterial ischemia, progressive venous congestion resulting in progressive myelopathy, space-occupying nature of the malformation and its venous drainage, and circulatory steal phenomenon. Most spinal vascular malformations come to clinical attention by nonspecific symptomatology that may be acute, subacute, or chronic. The initial clinical diagnosis is challenging and it is based on MRI; however, for better understanding and planning therapeutic strategy spinal angiogram is necessary. Once diagnosed, most spinal vascular malformations need treatment, as the natural history suggests progressive stepwise neurological deterioration. Early diagnosis and timely management in symptomatic patients can result in improvement or stabilization of clinical condition. Treatment should be performed in specialized centers. Except spinal cord cavernomas and spinal vascular tumors, all other vascular disorders are initially managed by endovascular embolization, as it is the least invasive but technically challenging and demanding procedure. For cases where embolization is technically not possible or when they fail embolization treatment, surgical treatment is an available option. In select cases a combined therapy might be sensible. Early diagnosis and prompt treatment are essential to alter the natural course and result in clinical improvement.