Malik Virender, Kannath Santhosh Kumar, Rajan Jayadevan Enakshy, Lukas Jospaul
Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India.
Neurointervention Center, Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Kerala, India.
World Neurosurg. 2018 Nov;119:267-273. doi: 10.1016/j.wneu.2018.08.021. Epub 2018 Aug 15.
The definitive treatment of perimedullary arteriovenous fistulas (PMAVFs) is warranted in view of the progressive neurologic decline noted with the conservative mode of management. The treatment options include microsurgical excision, endovascular embolization, or a multimodal approach. Because of the relatively larger size of the feeding arteries in type B and C PMAVFs, an endovascular approach is usually feasible. However, the endovascular treatment for type A lesions is technically challenging in view of near normal sized arterial feeders. Endovascular embolization using n-butyl cyanoacrylate is described; however, successful use of liquid embolic agents such as onyx or squid is not previously documented.
The described 3 cases initially presented with insidious onset and gradually progressive paraparesis, paresthesia, and urinary symptoms. The imaging (magnetic resonance and digital subtraction angiography) revealed type A PMAVFs. The microcatheter could be successfully navigated close to the fistulous site, and complete obliteration of the fistula was achieved using ethylene vinyl alcohol copolymer (EVOH)-based liquid embolic agent, squid in all of our cases. The occlusion remained durable, and patients showed steady neurologic improvement in the follow-up period.
Endovascular embolization of type A PMAVF using EVOH-based liquid embolic agent is feasible and could be considered as an effective alternative to surgery.
鉴于保守治疗方式下出现的进行性神经功能衰退，有必要对髓周动静脉瘘（PMAVFs）进行确定性治疗。治疗选择包括显微手术切除、血管内栓塞或多模式方法。由于B型和C型PMAVFs的供血动脉相对较粗，血管内治疗通常可行。然而，鉴于A型病变的供血动脉大小接近正常，血管内治疗在技术上具有挑战性。本文描述了使用正丁基氰基丙烯酸酯进行血管内栓塞的情况；然而，此前尚未有使用诸如Onyx或Squid等液体栓塞剂成功治疗的记录。
所描述的3例患者最初表现为隐匿起病，逐渐进展的双下肢轻瘫、感觉异常和泌尿系统症状。影像学检查（磁共振成像和数字减影血管造影）显示为A型PMAVFs。在所有病例中，微导管均能成功抵达瘘口附近，并使用基于乙烯-乙烯醇共聚物（EVOH）的液体栓塞剂Squid实现了瘘口的完全闭塞。闭塞效果持久，患者在随访期间神经功能持续改善。
使用基于EVOH的液体栓塞剂对A型PMAVF进行血管内栓塞是可行的，可被视为手术的有效替代方法。
