Yue He, Ling Wang, Ou Yibo, Chen Hanmin, Po Zhang, Wang Baofeng, Yu Jiasheng, Guo Dongsheng
Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, HuBei Province, 430030, PR China.
Department of Operating Room, Tongji Hospital, Tongji Medical College, Huazhong University, of Science and Technology, Wuhan, HuBei Province, 430030, PR China.
Clin Neurol Neurosurg. 2019 Sep;184:105371. doi: 10.1016/j.clineuro.2019.105371. Epub 2019 May 21.
Subarachnoid hemorrhage (SAH) or intraventricle hemorrhage (IVH) with negative cerebral digital subtraction angiography (DSA) results, which are due to non-cervical spinal arteriovenous lesions, are uncommon. In this article we presented three cases from our hospital and nineteen cases from prior published literature and discussed clinical features, possible mechanisms underlying the hemorrhage and therapeutic strategies for managing this unusual entity. Our analysis revealed that headache was the most common initial symptom. Almost 60% of patients had symptoms related to the spinal cord at admission. Intramedullary arteriovenous malformations (AVM) were the most common type of malformation, and the thoracic segment was the most common location of the non-cervical spinal arteriovenous lesions. More than half of the patients had additional aneurysms. Surgery was chosen as the primary treatment modality in this series. Therefore, we speculate that thoracolumbar spinal arteriovenous lesions are an unusual cause of intracranial SAH with negative cerebral DSA results. If non-cervical spinal AVMs were associated with DSA-negative SAH, the pattern of hemorrhage could be manifested as the blood in supratentorial cisterns, the fourth ventricle or no copious blood around the foramen magnum as well (somewhat paradoxically), it depends on the timing of detection and image evaluation. The formation and the rupture of associated aneurysms were the most likely immediate cause of the intracranial SAH. If non-cervical spinal AVMs were not associated with DSA-negative SAH and all cases were genuine cases of 'SAH-of-unknown origin', the spinal AVM could be considered as incidental finding. Magnetic resonance imaging (MRI) of the complete spinal neuraxis is recommended to either exclude or identify a spinal lesion in these patients. Catheter-based spinal angiography remains the gold standard for the diagnosis of spinal vascular diseases. The decision regarding a therapeutic strategy is based on the angioarchitecture and on the type of spinal arteriovenous lesions.
因非颈段脊髓动静脉病变导致脑数字减影血管造影（DSA）结果为阴性的蛛网膜下腔出血（SAH）或脑室内出血（IVH）并不常见。在本文中，我们展示了我院的3例病例以及先前发表文献中的19例病例，并讨论了其临床特征、出血的可能机制以及处理这一罕见病症的治疗策略。我们的分析显示，头痛是最常见的初始症状。近60%的患者入院时具有与脊髓相关的症状。髓内动静脉畸形（AVM）是最常见的畸形类型，胸段是非颈段脊髓动静脉病变最常见的部位。超过半数的患者伴有其他动脉瘤。本系列中选择手术作为主要治疗方式。因此，我们推测胸腰段脊髓动静脉病变是脑DSA结果为阴性的颅内SAH的罕见病因。如果非颈段脊髓AVM与DSA阴性的SAH相关，出血模式可能表现为幕上脑池、第四脑室内有血液，或者枕大孔周围也无大量血液（有点矛盾），这取决于检测时机和影像评估。相关动脉瘤的形成和破裂是颅内SAH最可能的直接原因。如果非颈段脊髓AVM与DSA阴性的SAH不相关且所有病例均为真正的“不明原因SAH”，则脊髓AVM可被视为偶然发现。建议对这些患者进行全脊柱神经轴的磁共振成像（MRI）以排除或识别脊髓病变。基于导管的脊髓血管造影仍是诊断脊髓血管疾病的金标准。治疗策略的决策基于血管构筑和脊髓动静脉病变的类型。
