Publications by authors named "Somkiet Siriwimonmas"

24 Publications

  • Page 1 of 1

Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula: A Case Report.

Asian J Neurosurg 2022 Mar 1;17(1):88-94. Epub 2022 Jun 1.

Division of Interventional Neuroradiology, Department of Radiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand.

Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8-9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8-9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
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http://dx.doi.org/10.1055/s-0042-1748791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9298594PMC
March 2022

Acquired Chiari malformation Type I and holocord syringomyelia associated with a high-flow supratentorial fistulous arteriovenous malformations: A case report and literature review.

Surg Neurol Int 2022 20;13:217. Epub 2022 May 20.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Chiari malformation Type I (CMI) is generally considered a congenital lesion and typically associated with syringomyelia. Acquired CMI or adult Chiari malformation caused by intracranial mass is extremely rare. Brain arteriovenous malformations (AVMs) are characteristically symptomatic due to seizure, intracranial hemorrhage, or neurological deficit. We report an extremely rare case of an acquired CMI and extensive syringomyelia associated with a large supratentorial AVM.

Case Description: A 35-year-old woman was referred to our institute after a diagnosis of CMI and extensive syringomyelia from whole-spine magnetic resonance imaging (MRI) due to complaining of low back pain radiating to the right leg for the past 1 month. She had intermittent headache for 2 years. The patient underwent suboccipital decompression and C1 laminectomy followed by duraplasty. Two months later, she developed severe right-sided sciatic pain and complete right foot drop. Follow-up MRI revealed progressive enlargement of a syrinx cavity at the lower spinal cord and a large right parieto-occipital AVM with markedly dilated cortical draining veins and diffuse engorgement of dural venous sinuses was detected. This AVM supplied mainly by enlarged cortical branches of the right middle cerebral artery and posterior cerebral artery with multiple dural supplies. Endovascular treatment of a high-flow fistulous AVM was successfully performed with N-butyl cyanoacrylate (NBCA) through the hypertrophic branches of the right middle cerebral artery. Four months after embolization, the patient had recovered completely from the right foot drop. Further staged embolization was planned to reduce the size and flow of the AVM before stereotactic radiosurgery. However, the patient was lost to follow-up due to financial reason. One year later, she developed sudden severe headache followed by alteration of conscious due to intraventricular hemorrhage from the AVM, leading to obstructive hydrocephalus requiring cerebrospinal fluid diversion. During a period of 2 years, the patient underwent several staged embolization with NBCA and Onyx. Final cerebral angiography after embolization demonstrated a significant reduction in size and flow of the brain AVM. A control whole-spine MRI revealed a significant reduction in syrinx size. At the end of embolization, the patient had no neurological deficit. However, she had suffered from persistent central neuropathic pain at the right lower extremity. The AVM remnant was further treated by stereotactic radiosurgery.

Conclusion: Increased cerebral venous hypertension secondary to a high-flow supratentorial AVM leading to posterior fossa venous hypertension may play a major role in the pathogenesis of CMI, induced the formation of syringomyelia. Endovascular treatment of brain AVM, the underlying cause of CMI, resulted in a significant reduction of the size of the syrinx. The need for cranial imaging in initial evaluation of cases with adult Chiari malformation is important.
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http://dx.doi.org/10.25259/SNI_11_2022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9168309PMC
May 2022

Sacral dural arteriovenous fistula of the filum terminale coexisting with partially thrombosed filum vein: A case report and literature review.

Surg Neurol Int 2022 4;13:78. Epub 2022 Mar 4.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually classified as intradural ventral AVFs or Type IVa perimedullary fistulas, located on the pia surface along the course of filum terminale internum (FTI). We report an extremely rare case of sacral dural arteriovenous fistula of the FT. We also review the occurrence of FTAVFs in the sacral region.

Case Description: A 64-year-old man presented with progressive weakness of the lower extremities for 3 months and bowel/bladder dysfunction following long history of back pain radiating to both legs. Magnetic resonance imaging of the lumbosacral and thoracic spine showed spinal cord congestion, extending from the conus medullaris to the level of T3, and partial thrombosis within the abnormal tortuous and dilated flow void, running from the sacral area to conus medullaris. Further findings were compression fracture of L2 vertebra, Grade I degenerative spondylolisthesis at the level of L2-3, and L3-4, and spinal stenosis at L2-3, L3-4, and L4-5. Spinal angiography, maximum intensity projection reformatted image of angiographic computerized tomography, and three-dimensional reconstructed image clearly demonstrated dural AVF of the FT at the level of S2 supplied by bilateral lateral sacral and middle sacral arteries with cranial drainage to perimedullary vein through the enlarged vein of the filum. The patient was indirectly treated by transection of the filum terminale and the draining vein at the level of L5 rostral to the fistula.

Conclusion: Sacral DAVFs of the FT are extremely rare. In our case, the formation of fistula may cause by venous hypertension secondary to partial thrombosis within the filum vein, probably resulting from long-standing spinal canal stenosis. Sacral FTAVFs may be found on the pia surface of the terminal FTI, dural component at the area of dural sac termination, or dural extension covering the filum terminale externum.
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http://dx.doi.org/10.25259/SNI_980_2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8986650PMC
March 2022

Transfemoral transvenous embolization through the vein of Trolard and superficial middle cerebral vein for cavernous sinus dural arteriovenous fistula with isolated cortical vein drainage: A case report and literature review.

Surg Neurol Int 2022 29;13:34. Epub 2022 Jan 29.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Endovascular treatment may be challenging for cavernous sinus dural arteriovenous fistulas (CSDAVFs) with prominent leptomeningeal drainage without other accessible routes. We report a case of CSDAVF with isolated cortical venous successfully drainage treated by percutaneous transvenous embolization through the vein of Trolard and superficial middle cerebral vein (SMCV). We also review the literature of CSDAVFs treated by transvenous embolization through SMCV with or without combined surgical approach.

Case Description: A 46-year-old woman presented with ocular symptoms and delayed treatment was encountered due to the COVID-19 pandemic. Cerebral angiography showed a CSDAVF (Barrow type D, Borden II, and Cognard II a + b) with isolated cortical vein drainage. Percutaneous transvenous access to the fistula through the inferior petrosal sinus was attempted but failed. Transvenous embolization through the vein of Trolard and SMCV was further attempted, and satisfactory occlusion of the fistula was achieved with detachable coils. This access route was chosen because of the occlusion of other access routes and can obliterate the need for more invasive approach, that is, combined surgical and endovascular approach. Cerebral angiography obtained 6 months following the procedure, confirmed complete angiographic obliteration of the fistula. The patient made an uneventful recovery.

Conclusion: To avoid invasive combined surgical and endovascular approach, transvenous embolization through the vein of Trolard and SMCV may be another accessible option for treating CSDAVF with isolated cortical venous drainage.
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http://dx.doi.org/10.25259/SNI_1162_2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8888315PMC
January 2022

Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula.

Asian J Neurosurg 2021 Jul-Sep;16(3):638-644. Epub 2021 Sep 14.

Department of Radiology, Division of Interventional Neuroradiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand.

Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8-9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8-9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.
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http://dx.doi.org/10.4103/ajns.ajns_185_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477807PMC
September 2021

Cauda equina arteriovenous fistula supplied by proximal radicular artery and concomitant sacral dural arteriovenous fistula: A case report and literature review.

Surg Neurol Int 2021 16;12:405. Epub 2021 Aug 16.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Cauda equina arteriovenous fistulas (AVFs) fed by the proximal radicular artery are exceedingly rare. Spinal dural arteriovenous fistulas (DAVFs) in the sacral region are rare and usually misdiagnosed. We report a case of a cauda equina AVF with concomitant sacral DAVF. We also review the coexistence of multiple types of spinal vascular malformations in a single patient.

Case Description: A 54-year-old man presented with progressive weakness of the lower extremities for 1 month. Magnetic resonance imaging (MRI) of the lumbosacral and thoracic spine showed spinal cord congestion, extending from the conus medullaris to the level of T7, and abnormal tortuous and dilated flow void, running from the level of L5 to T12 along anterior surface of the spinal cord. Spinal angiography demonstrated the fistula at the level of L2 below the conus medullaris. Based on intraoperative findings, the cauda equina AVF supplied by the proximal radicular artery with cranial drainage through the enlarged radicular vein was confirmed and successfully obliterated. Another enlarged arterialized radicular vein running parallel to another cauda equina nerve root is observed with unknown origin. After the operation, the patient showed mild improvement of his symptoms. Follow-up MRI and contrast-enhanced MR angiography revealed an another sacral DAVF vascularized by the lateral sacral artery.

Conclusion: The coexistence of different spinal vascular malformations in a same patient is extremely rare. Most authors of several studies hypothesized that venous hypertension and thrombosis due to the presence or treatment of the first spinal vascular lesion may produce a second DAVF.
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http://dx.doi.org/10.25259/SNI_612_2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8422537PMC
August 2021

Filum Terminale Arteriovenous Fistula with Additional Arterial Supply by the Posterior Spinal Artery: A Report of Two Cases.

Asian J Neurosurg 2021 Apr-Jun;16(2):423-430. Epub 2021 May 28.

Department of Anatomy, Faculty of Medicine, Khon Kaen University, Bangkok, Thailand.

Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually supplied by the artery of the filum terminale, distal termination of the anterior spinal artery (ASA). These fistulas may also supply from the lateral sacral artery (LSA) arising from the internal iliac artery and/or middle sacral artery. Additional supply by the posterior spinal artery (PSA) has never been mentioned before. The authors describe two middle-aged men harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction. The first fistula was supplied by the ASA with additional supply by the dilated PSA connecting with the ASA. Another fistula was supplied by the LSA and the PSA communicating with the ASA. The first case was successfully treated by endovascular treatment with N-butyl cyanoacrylate through the enlarged PSA, whereas the second case was surgically treated by direct obliteration of the fistula. Both patients had good neurological outcome.
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http://dx.doi.org/10.4103/ajns.AJNS_528_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244683PMC
May 2021

Filum Terminale Arteriovenous Fistula Coexisting with a Large L2-L3 Disc Sequestration and Associated Diffuse Lumbar Arachnoiditis.

Asian J Neurosurg 2021 Apr-Jun;16(2):412-417. Epub 2021 May 28.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

The authors describe a case of filum terminale arteriovenous fistula (FTAVF) in association with a large L2-L3 disc sequestration and diffuse lumbar arachnoiditis. A 64-year-old male manifested with chronic back pain and gait difficulty. Magnetic resonance imaging (MRI) of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T9. There was a large disc sequestration came from L2-L3 disc herniation. In addition, thickening, clumping, and enhancement of the entire cauda equina were noted, probably representing arachnoiditis. MR angiography (MRA) and spinal angiography confirmed FTAVF at the level of L5. The patient underwent laminectomy with lysis adhesions and obliteration of the fistula. His postoperative course was uneventful. MRI and MRA of the thoracolumbar spine obtained 4 months after surgery revealed complete obliteration of the fistula and significant resolution of spinal cord congestion. Enhancement of the cauda equina roots was no longer visible. Interestingly, the significant resorption of the sequestrated disc was documented on MRI. The formation of the FTAVF in the present study may result from severe spinal canal stenosis caused by a large disc sequestration blocking the rostral venous drainage of the fistula, or chronic inflammation, and adhesions of the caudal nerve roots from lumbar arachnoiditis. It seems that FTAVF may be of acquired origin by this evidence.
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http://dx.doi.org/10.4103/ajns.AJNS_489_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244695PMC
May 2021

Spinal epidural arteriovenous fistula with intradural venous reflux: The possibility of acquired origin caused by spinal stenosis and/or disc herniation.

Clin Neurol Neurosurg 2021 08 2;207:106794. Epub 2021 Jul 2.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand. Electronic address:

Background: Spinal epidural arteriovenous fistulas (SEAVFs) are relative rare lesions. The pathogenesis of these fistulas remains unclear. Our aim is to review cases of SEAVFs at our institution.

Methods: We reviewed a consecutive series of spinal vascular disease at our institution and collected all patients harboring SEAVFs. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, previous history of spinal surgery or trauma, treatment methods, and neurological outcome after treatment. All image studies, including plain radiography, spinal MRI, MRA, and angiography were analyzed.

Results: We identified 9 cases of lumbosacral SEAVFs with intradural venous reflux treated at our institution from June 2010 to August 2020. Their median age was 67 years, range 52-83 years. Only one patient had a history of trauma. Interestingly, our observations found that all fistulas are associated with spinal stenosis and/or disc herniation. An additional literature search about SEAVFs coexisting with spinal stenosis and/or disc herniation was performed and found another 19 cases with median age 69 years, range 39-83 years. Only 2 patients had a history of previous spinal surgery. The level of shunted pouch in all 28 patients was correlated with the level of spinal canal stenosis and/or disc herniation.

Conclusions: Our study may provide an additional evidence supporting an acquired etiology of SEAVFs, which mainly manifest in late adulthood. It is possible that spinal stenosis and/or disc herniation may result in thrombosis or impairment of venous drainage, causing increased venous pressure, leading to fistulous formation.
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http://dx.doi.org/10.1016/j.clineuro.2021.106794DOI Listing
August 2021

Acquired Lumbosacral Spinal Dural Arteriovenous Fistula in Association with Degenerative Lumbosacral Disc Herniation and Spinal Canal Stenosis: Report of Two Cases and Review of the Literature.

Asian J Neurosurg 2020 Oct-Dec;15(4):1059-1067. Epub 2020 Oct 19.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

The authors describe two cases harboring lumbosacral spinal dural arteriovenous fistulas (SDAVFs) manifested with nonspecific initial symptoms, leading to misdiagnosis and unnecessary procedures. A curvilinear flow void in the lumbar region and thoracic cord congestion with subtle perimedullary flow voids were detected on magnetic resonance imaging (MRI) in both patients. Contrast-enhanced magnetic resonance angiography and spinal angiography confirmed the SDAVFs in the lower lumbar and sacral region. Both fistulas were located at the same level of disc herniation and spinal canal stenosis and supplied by branches of the internal iliac arteries (i.e., iliolumbar and lateral sacral arteries) with cranial drainage from the dilated vein of the filum terminale, corresponding to a curvilinear flow void, to the perimedullary veins. The first case was successfully treated with embolization. Another case had recanalization of the fistula 4 months after endovascular treatment and was successfully treated with surgical interruption of the fistula. Our two case reports may provide additional evidence supporting an acquired etiology of SDAVFs, probably secondary to lumbosacral disc herniation and spinal canal stenosis. The authors also reviewed literature about preexistent lumbosacral SDAVFs associated with disc herniation and spinal canal stenosis. From our review, the level of SDAVFs in most patients is correlated with the level of disc herniation, spondylolisthesis, and/or spinal stenosis.
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http://dx.doi.org/10.4103/ajns.AJNS_318_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869260PMC
October 2020

Spontaneous Spinal Osseous Epidural Arteriovenous Fistula with Long Segments of Prominent Epidural Venous Drainage Causing Severe Compressive Thoracic Myelopathy Successfully Treated with Combined Endovascular and Surgical Treatments: A Case Report and Review of the Literature.

Asian J Neurosurg 2020 Oct-Dec;15(4):1041-1049. Epub 2020 Oct 19.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

The authors describe an extremely rare case of spinal osseous epidural arteriovenous fistulas (SOEAVFs) with unique characteristic features. A 25-year-old man presented with progressive weakness and paresthesia of the lower extremities for 1 month. Magnetic resonance imaging of the thoracic spine showed an extradural dilated vascular flow void structure extending from T4 to T8 levels with abnormal hyperintense T2 signal from T6 to T8 levels. Magnetic resonance angiography and spinal angiography revealed unique features of SOEAVF supplied by multiple small arterial feeders of intercostal arteries converging into a dilated round venous sac corresponding to a bony defect of T7 lamina and spinous process. The venous drainage directly drained into prominent epidural venous plexus extending from the level of T4 to T8 without intradural venous drainage, causing severe compressive myelopathy. Transarterial embolization was performed using N-butyl cyanoacrylate through the main feeder. Subsequently, he successfully underwent laminectomy and total excision of the fistula and large epidural draining venous plexus. Histopathology confirmed spinal vascular malformations with evidence of previous embolization. He gradually improved until being ability to walk independently 3 months later. Follow-up spinal angiography confirmed complete resection of SOEAVF. The patient has remained clinically asymptomatic 5 years after operation.
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http://dx.doi.org/10.4103/ajns.AJNS_353_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869281PMC
October 2020

Intramedullary Hemorrhage Caused by Lumbosacral Epidural Arteriovenous Fistula with Dual Retrograde Perimedullary Venous Draining Routes: A Case Report and Review of the Literature.

World Neurosurg 2020 11 10;143:295-307. Epub 2020 Aug 10.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Spinal epidural arteriovenous fistulas (SEAVFs) are rare lesions with a low risk of hemorrhage. Most patients with lumbosacral SEAVFs with hemorrhagic events will develop a spinal epidural hematoma from epidural venous pouches. To the best of our knowledge, we have reported the first case of a lumbosacral SEAVF presenting with remote intramedullary hemorrhage in the conus medullaris.

Case Description: A 56-year-old man presented with sudden-onset severe paraparesis and bowel/bladder dysfunction. Magnetic resonance imaging of the thoracic and lumbosacral spine showed acute intramedullary hemorrhage in the conus medullaris surrounded by spinal cord congestion extending to T8, with perimedullary flow voids along the ventral and dorsal cord surfaces. Magnetic resonance angiography and spinal angiography confirmed the presence of a SEAVF with a large lumbosacral epidural venous lake supplied by dorsal somatic branches of bilateral L4 segmental arteries. Initially, the intradural venous drainage had been misinterpreted as a single route. The patient underwent surgical interruption of the dilated intradural draining vein after embolization of the feeding vessels. Another small intradural venous drainage route was found on the follow-up angiogram. The second operation with occlusion of the initial part of the epidural venous lake was sufficient to cure this lesion.

Conclusions: With the significant improvement of our patient after treatment of the SEAVF, we speculated that the intramedullary hemorrhage, which had occurred in the area of spinal cord edema, might have resulted from severe venous hypertension, rather than hemorrhagic infarction of the spinal cord. Careful evaluation of the angioarchitecture of SEAVFs is imperative to determine the most effective treatment modality.
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http://dx.doi.org/10.1016/j.wneu.2020.08.025DOI Listing
November 2020

Sacral Extradural Angiolipoma Associated with Tight Filum Terminale and Spina Bifida Coexisting with Spinal Arteriovenous Fistula.

World Neurosurg 2020 08 11;140:37-45. Epub 2020 May 11.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Spinal arteriovenous fistula (AVF) may rarely associate with spinal dysraphism, that is, tethered spinal cord and spinal intradural lipoma. Spinal extradural angiolipoma coexisting with spinal AVF has not been reported in the literature. We reported an extremely rare case of sacral angiolipoma associated with tight filum terminale and sacral spina bifida coexisting with spinal AVF within this tumor.

Case Description: A 55-year-old women presented with progressive myelopathy for 10 months. She had a painless, slow-growing mass at her left buttock since birth. Magnetic resonance imaging of the lumbosacral spine showed an extradural mass at the level of S3-S4, extending from the spinal canal through the spina bifida to the subcutaneous fat of the left buttock. There was a low conus medullaris at S2. Magnetic resonance imaging of the thoracic spine disclosed venous congestion with tortuous intradural flow voids along both ventral and dorsal surfaces of the spinal cord. Magnetic resonance angiography and spinal angiography revealed a hypervascular mass at the sacral level and associated arteriovenous shunt with cranial drainage into an enlarged medullary vein. Due to an infected pressure sore on the mass, endovascular treatment was initially performed with minimal recovery. Six months after complete healing of her infected pressure ulcer, the patient underwent surgical removal of extradural mass containing the AVF, and subsequent release of the tight filum. Histologic findings were consistent with angiolipoma.

Conclusions: Sacral extradural angiolipoma in the present case may be congenital in origin with development of an acquired spinal AVF within the tumor.
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http://dx.doi.org/10.1016/j.wneu.2020.04.239DOI Listing
August 2020

Reversible Thalamic Dementia Caused by Venous Hypertension of Bilateral Thalami Resulting from Multiple Intracranial Dural Arteriovenous Fistulas Successfully Obliterated by Endovascular Treatment using Liquid Embolic Materials: A Case Report and Literature Review.

Asian J Neurosurg 2020 Jan-Mar;15(1):144-154. Epub 2020 Feb 25.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

We describe a patient with multiple cranial dural arteriovenous fistulas (DAVFs) presenting with thalamic dementia. A 52-year-old man experienced progressive dementia and behavioral change for 1 month. Cranial computed tomography scan and magnetic resonance imaging (MRI) showed bilateral thalamic edema with subsequent hemorrhagic transformation. Cerebral angiography demonstrated multiple cranial DAVFs at the straight sinus and posterior part of the superior sagittal sinus. The symptomatic fistula was the straight sinus DAVF, Cognard Type II a + b, supplied by meningeal branches of the left superior cerebellar artery, the left ascending pharyngeal artery originating from the left occipital artery, and multiple tiny branches of the left occipital artery with retrograde venous drainage into the straight sinus and vein of Galen. In addition, there was probable thrombosis at the middle part of the straight sinus associated with anatomical variation of the dural venous sinuses at the torcular herophili. The patient underwent successfully endovascular treatments in a two-staged embolization using liquid embolic materials. The patient has gradually recovered and could get back to the activities of daily living at home within 2 months. Follow-up MRI of the brain at 6 months revealed nearly complete resolution of the bilateral thalamic congestion. Cerebral angiography, obtained 1 year after endovascular treatment, confirmed complete obliteration of both DAVFs. We also reviewed the literature of thalamic dementia caused by intracranial DAVFs.
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http://dx.doi.org/10.4103/ajns.AJNS_317_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057878PMC
February 2020

Filum Terminale Arteriovenous Fistula in Association with Degenerative Lumbosacral Spinal Canal Stenosis: Report of 3 Cases and Review of the Literature.

World Neurosurg 2020 06 10;138:231-241. Epub 2020 Mar 10.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Filum terminale arteriovenous fistulas (FTAVFs) are rare, and the pathogenesis of these fistulas remains unclear. They may be either congenital or acquired in origin. The authors report 3 cases of FTAVFs in association with severe spinal canal stenosis. The authors also review literature of FTAVFs associated with spinal canal stenosis.

Case Description: All 3 cases harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction following long history of back pain, sciatica, and/or intermittent claudication. The fistulas were located around or at the level of spinal canal stenosis and supplied by the anterior spinal and/or lateral sacral arteries with cranial drainage from the dilated vein of the filum terminale to the perimedullary veins. The first and third cases were treated concomitantly by performing instrumented fusion with decompressive laminectomy along with occlusion of the fistula with good results. The second case was unsuccessfully treated by endovascular treatment through the lateral sacral artery and denied further surgical treatment.

Conclusions: Our 3 case reports may provide additional evidence supporting an acquired etiology of FTAVFs, probably secondary to the severe central canal stenosis. From our review, the level of the fistulas in most patients is correlated with the level of spinal canal stenosis. The authors preferred the concomitant surgical treatment by performing decompressive laminectomy and obliteration of the fistula in the same surgical session.
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http://dx.doi.org/10.1016/j.wneu.2020.03.011DOI Listing
June 2020

Spinal Sparganosis Coexisting with Acquired Arteriovenous Fistula of the Filum Terminale.

World Neurosurg 2020 Apr 26;136:341-347. Epub 2020 Jan 26.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Background: Spinal sparganosis associated with filum terminale arteriovenous fistula (FTAVF) has not been reported in the literature. In previous studies, these 2 rare diseases were usually reported separately. We report the first case of spinal sparganosis with concomitant FTAVF.

Case Description: Spinal sparganosis associated with FTAVF manifested in a middle-aged man with progressive back pain and paraparesis. Magnetic resonance imaging of the lumbosacral spine revealed large intradural mass-like lesions involving the conus medullaris and entire cauda equina. Additionally, there was degenerative spinal stenosis at the level of L2-3 to L5-S1. Magnetic resonance imaging of the thoracic spine disclosed abnormal hypersignal intensity extending from the level of the conus medullaris to T7 with tortuous intradural flow voids along the ventral more than dorsal surfaces of the spinal cord. Magnetic resonance angiography and spinal angiography confirmed FTAVF at the level of L3-4. The patient underwent surgical removal of the granulation tissues with lysis adhesions and obliteration of the FTAVF simultaneously in the same surgical session. Histologic findings were consistent with sparganosis.

Conclusions: The formation of FTAVF in the present case may have resulted from severe spinal canal stenosis caused by lumbar spondylosis and spinal sparganosis, inducing chronic inflammation and severe adhesion of spinal nerve roots. This evidence indicates that FTAVF may have been acquired.
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http://dx.doi.org/10.1016/j.wneu.2020.01.132DOI Listing
April 2020

Spontaneous Closure of a Cavernous Sinus Dural Arteriovenous Fistula with Spinal Perimedullary Drainage (Cognard V) during Attempted Transvenous Embolization.

Asian J Neurosurg 2019 Oct-Dec;14(4):1268-1274. Epub 2019 Nov 25.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

The authors describe a patient with spontaneous closure of a spontaneous cavernous sinus dural arteriovenous fistula (CSDAVF), Cognard type V, during transvenous attempt. A 39-year-old woman experienced mild proptosis, redness of the left eye, and diplopia. Four months later, she developed left retro-orbital pain and left-sided headache. Cerebral angiography revealed the left CSDAVF exclusively draining into the superior petrosal sinus with subsequent drainage into the veins surrounding the medulla oblongata, and finally into the perimedullary spinal veins, classified as Cognard type V. The feeders arise from the dural branches of both the left external and internal carotid arteries. Following 2 h period of attempted transvenous embolization, the fistula disappeared spontaneously. Follow-up angiography obtained 6 months later confirmed complete resolution of the CSDAVF. At 2-year follow-up, the patient has remained clinically asymptomatic. The mechanism of thrombosis in this fistula related to the endovascular procedure. We speculated that putting the wire tip in the draining vein may induce the spontaneous thrombosis in the venous side. In addition, precipitating factors may include small, low-flow fistula, and pre-existing thrombosis.
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http://dx.doi.org/10.4103/ajns.AJNS_277_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896619PMC
November 2019

Medullary Hemorrhage Caused by Foramen Magnum Dural Arteriovenous Fistula Successfully Obliterated using Combination of Endovascular and Surgical Treatments: A Case Report and Literature Review.

Asian J Neurosurg 2019 Oct-Dec;14(4):1256-1267. Epub 2019 Nov 25.

Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

The authors describe an extremely rare case of foramen magnum dural arteriovenous fistula (DAVF), Cognard type V, presented with medullary hemorrhage caused by venous varix on the lateral medullary draining vein embedded into the medulla oblongata. Following mild myelopathy for 3 days, a 20-year-old male developed dyspnea, generalized seizures, loss of consciousness, and finally cardiac arrest. After successful resuscitation, computed tomography scan (CT) of the brain was obtained and showed acute medullary hemorrhage. Subsequent magnetic resonance imaging of the brain revealed diffuse venous congestion or edema of the medulla with multiple dilated flow voids surrounding the medulla, more prominent on the left side, with venous varix embedded into the left-sided of the lower medulla. He was sent to the emergency department of the local hospital and intubated promptly. A few minutes later, the patient had a cardiac arrest. Digital subtraction angiography (DSA) demonstrated DAVF of the foramen magnum supplied mainly by dural branches of bilateral hypertrophic posterior inferior cerebellar arteries (PICAs), slightly by the posterior meningeal branch of the left vertebral artery, and the jugular branch of the left ascending pharyngeal artery (APA) originating from the occipital artery. Transarterial embolization through the bilateral dural branches of the PICAs was successfully performed using N-butyl-2-cyanoacrylate (NBCA), resulting in complete obliteration. The patient had excellence recovery and lost to annual follow-up. Seven years later, he had a recurrent of the fistula presented with occipital headache. DSA with angiographic CT in three-dimensional reconstruction and maximum intensity projection reformatted images clearly demonstrated the exact location of the DAVFs at the posterior rim of the foramen magnum, mainly recruited by the hypertrophic jugular branch of the APA originating from the occipital artery. The fistula was successfully treated surgically following transarterial embolization through the jugular branch of the APA using NBCA. Follow-up DSA confirmed complete obliteration of the DAVF. The patient has remained clinically asymptomatic 2 years after the operation.
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http://dx.doi.org/10.4103/ajns.AJNS_259_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896611PMC
November 2019

Spontaneous resolution of direct carotid-cavernous fistulas: case series and literature review.

Interv Neuroradiol 2019 Feb 23;25(1):71-89. Epub 2018 Sep 23.

3 Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

Spontaneous regression of direct carotid-cavernous fistulas (CCFs) is extremely rare. Most of the patients with direct CCFs are usually treated using endovascular techniques. Spontaneous obliteration of the direct fistulas probably results from thrombosis of the venous drainage and/or cavernous sinus. We report spontaneous closure of nine direct CCFs in nine patients. From literature review, we found another 37 patients with 43 fistulas due to spontaneous obliteration of bilateral lesions in six cases. There was no spontaneous closure in large-sized fistula. The factors associated with spontaneous thrombosis of the fistulas may be low-flow and small-sized fistula, hypotension, severe ocular manifestations, dissections or spasm of carotid artery, and increased intracranial pressure. Spontaneous healing of direct traumatic CCFs should be confirmed with cerebral angiography. Conservative treatment of direct CCFs should be carefully restricted in patients with normal vision or minimal visual impairment, and the patients must be monitored closely for any changes in visual function. Prompt endovascular treatment for complete obliteration of the fistula should be performed in patients with rapidly progressive visual loss. Venous thrombosis can still effect vision and rerouting towards cortical veins remains a concern. Because spontaneous resolution cannot be reliably predicted, the fistula then should be treated rather than waiting for spontaneous thrombosis.
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http://dx.doi.org/10.1177/1591019918800220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378520PMC
February 2019

Contralateral extensive cerebral hemorrhagic venous infarction caused by retrograde venous reflux into the opposite basal vein of Rosenthal in posttraumatic carotid-cavernous fistula: A case report and literature review.

Interv Neuroradiol 2018 Oct 19;24(5):546-558. Epub 2018 May 19.

3 Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand.

We describe a patient with traumatic carotid-cavernous fistula (CCF), subsequently developing contralateral extensive hemorrhagic venous infarction from retrograde venous reflux into the opposite basal vein of Rosenthal. A 54-year-old woman was involved in a motor vehicle accident and sustained severe traumatic brain injury. Two months later, she developed bilateral proptosis and audible bruit. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain demonstrated the right direct CCF. Fluid-attenuated inversion recovery (FLAIR) images showed a small hyperintense area at the left basal ganglia. Ten days later, she developed right-sided grade 2/5 hemiparesis, facial upper motor neuron weakness, and cognitive impairment. Follow-up MRI showed significant progression of hyperintensities involving the left-sided centrum semiovale, basal ganglia, thalamus, midbrain, pons, cerebellum, basal frontal, temporal lobes, especially subcortical white matter on FLAIR images, and multiple hypointense foci of hemorrhagic component on T2*-weighted gradient-echo images, representing hemorrhagic venous infarction. While waiting for embolization, she rapidly developed right hemiplegia and aphasia, and became somnolent. Under general anesthesia, emergency endovascular treatment was performed successfully to obliterate the fistula without surgical intervention. Five months after endovascular treatment, MRI and MRA confirmed no residual fistula and revealed nearly complete resolution of abnormal increased signal intensity. In the present case, the factors related to the presence of this rare condition were absence of the ipsilateral basal vein of Rosenthal (BVR), occlusion of posterior segment of the contralateral superior petrosal sinus, and a developed uncal vein with hypoplastic second and third segments of the contralateral BVR.
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http://dx.doi.org/10.1177/1591019918776615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116133PMC
October 2018

Spontaneous obliteration of spontaneous vertebral arteriovenous fistula associated with fibromuscular dysplasia after partial surgery: A case report.

Interv Neuroradiol 2016 Dec 1;22(6):717-727. Epub 2016 Aug 1.

Department of Radiology, Bumrungrad International Hospital, Thailand.

We describe a patient with spontaneous obliteration of spontaneous vertebral arteriovenous fistula (VAVF) associated with fibromuscular dysplasia (FMD) after partial surgery. A 52-year-old hypertensive female woke up one morning with left shoulder pain and weakness of the left upper extremity. A few days later, she developed left-sided audible bruit. She was treated for left frozen shoulder and supportive treatment for audible bruit for four years. She was referred from her general physician to a neurosurgeon because of left arm weakness. Physical examination showed signs of cervical radiculomyelopathy. Magnetic resonance imaging (MRI) showed an extradural mass on the left side of the cervical spinal canal from level C2 to C6. Provisional diagnosis was epidural vascular tumour. Laminectomy and partial removal of the mass was performed at level C5 to C6. Pathological report revealed suspected vascular malformation. Postoperative MRI showed thrombosed epidural vascular structure. Angiography showed dysplastic changes of both vertebral arteries representing FMD with VAVF of the left vertebral artery at level C1-C2. Two years after surgery, follow-up MRI demonstrated complete spontaneous resolution of the large thrombosed epidural vein. Disappearance of her audible bruit immediately after surgery and gradual improvement of her cervical radiculomyelopathy were observed after two years of clinical follow-up. From the literature, we found another 11 patients with 12 VAVFs who had spontaneous obliteration or cure of their fistulas. In the present case, spontaneous obliteration of the fistula seems to correlate with surgery inducing closure of the epidural venous exit leading to thrombosis of the enlarged epidural draining vein.
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http://dx.doi.org/10.1177/1591019916659263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5564354PMC
December 2016

Intracranial Hypertension in Unruptured Arteriovenous Malformation: Case Report.

J Med Assoc Thai 2016 Jun;99 Suppl 3:S130-6

A report of intracranial hypertension in unruptured cerebral arteriovenous malformation (AVMs) is presented. A 16-years-old obese female presented with a first episode of acute severe headache and papilledema. Non-contrasted computer tomography scan demonstrated no evidence of hemorrhage or hydrocephalus. The magnetic resonance imaging brain shows the unruptured AVMs at right temporal area. The AVMs was urgently embolized by glue. Headache completely disappeared within two weeks. The papilledemagradually improved within two weeks and completely recovered within six weeks. Patients with unruptured AVMs should undergo early intervention, either by means of surgical excision or embolization, so as to avoid the permanent deficits of optic nerve such as decreased visual acuity and impaired visual field and optic atrophy.
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June 2016

Pre-operative Embolization of Intracranial and Extracranial Tumors: A Review of 37 Cases

J Med Assoc Thai 2016 Jun;99 Suppl 3:S91-119

Objective: To examine the safety and efficacy of pre-operative embolization of intra-and extracranial tumors and determine the selection criteria of patients for this procedure.

Material And Method: Between June 2008 and August 2012, 37 patients (17 males, 20 females; mean age, 44.2+14.2years), underwent pre-operative embolization of intra- and extracranial tumors, were retrospectively reviewed. Tumor characteristics (type, location, volume, percentage of supplying artery, presence of an early draining vein), angiographic extent of tumor devascularization, timing between embolization and surgery, estimated blood loss, and complication related embolization were evaluated.

Results: There were 37 tumors (mean volume, 90.9+83.6 cm3) composed of 18 meningiomas, six hemangioblastomas, six hemangiopericytomas, one metastasis, one osteoblastoma, one osteosacroma, one neurofibroma, one central neurocytoma, one glomus jugulare, one mixed oligoastrocytoma, and one glioblastoma multiforme. Early of draining veins were visualized in 24 patients (64.9%). Failure of pre-operative embolization occurred in four patients. Median time to surgery after embolization was seven days (ranged 1-171 days). There was statistically significant difference between grading of angiographic devascularization and estimated blood loss (p = 0.009, Kruskal-Wallis test). Two patients (5.4%) had embolization-related complications, including hemorrhage during sub-selective catheterization and postoperative scalp necrosis.

Conclusion: Although pre-operative embolization of intra- and extracranial tumors was safe, only extensive or complete angiographic devascularization has been effective in less intra-operative blood loss. From this present study, indications regarding when to perform pre-operative embolization include history of excessive bleeding from previous surgery, known hypervascular tumor types (e.g., hemangiopericytoma, hemangioblastoma, paraganglioma), the presence of multiple flow voids on MRI, hypervascular tumors of skull or scalp, deep-seated tumors (e.g., cranial base tumor, intraventricular tumor) with difficulty in early surgical access of the main feeding vessels, and tumors associated with intratumoral aneurysm.
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June 2016

Pre-operative Embolization of Intracranial and Extracranial Tumors: A Review of 37 Cases.

J Med Assoc Thai 2016 Jun;99 Suppl 3:S91-119

Objective: To examine the safety and efficacy of pre-operative embolization of intra-and extracranial tumors and determine the selection criteria of patients for this procedure.

Material And Method: Between June 2008 and August 2012, 37 patients (17 males, 20 females; mean age, 44.2+14.2years), underwent pre-operative embolization of intra- and extracranial tumors, were retrospectively reviewed. Tumor characteristics (type, location, volume, percentage of supplying artery, presence of an early draining vein), angiographic extent of tumor devascularization, timing between embolization and surgery, estimated blood loss, and complication related embolization were evaluated.

Results: There were 37 tumors (mean volume, 90.9+83.6 cm3) composed of 18 meningiomas, six hemangioblastomas, six hemangiopericytomas, one metastasis, one osteoblastoma, one osteosacroma, one neurofibroma, one central neurocytoma, one glomus jugulare, one mixed oligoastrocytoma, and one glioblastoma multiforme. Early of draining veins were visualized in 24 patients (64.9%). Failure of pre-operative embolization occurred in four patients. Median time to surgery after embolization was seven days (ranged 1-171 days). There was statistically significant difference between grading of angiographic devascularization and estimated blood loss (p = 0.009, Kruskal-Wallis test). Two patients (5.4%) had embolization-related complications, including hemorrhage during sub-selective catheterization and postoperative scalp necrosis.

Conclusion: Although pre-operative embolization of intra- and extracranial tumors was safe, only extensive or complete angiographic devascularization has been effective in less intra-operative blood loss. From this present study, indications regarding when to perform pre-operative embolization include history of excessive bleeding from previous surgery, known hypervascular tumor types (e.g., hemangiopericytoma, hemangioblastoma, paraganglioma), the presence of multiple flow voids on MRI, hypervascular tumors of skull or scalp, deep-seated tumors (e.g., cranial base tumor, intraventricular tumor) with difficulty in early surgical access of the main feeding vessels, and tumors associated with intratumoral aneurysm.
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June 2016
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