Imaging in Spinal Vascular Disease

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Spinal vascular diseases are rare and constitute only 1% to 2% of all vascular neurologic pathologies. In this article, the following vascular pathologies of the spine are described: spinal arterial infarcts, spinal cavernomas, and arteriovenous malformations (including perimedullary fistulae and glomerular arterivenous malformations), and spinal dural arteriovenous fistulae. This article gives an overview about their imaging features on MRI, MR angiography, and digital subtraction angiography. Clinical differential diagnoses, the neurologic symptomatology, and the potential therapeutic approaches of these diseases, which might vary depending on the underlying pathologic condition, are given.

Section snippets

Anatomy

To interpret MRI and DSA findings of spinal vascular diseases, it is necessary to be aware of the normal arterial supply and venous drainage of the spine and spinal cord. Segmental arteries supply the spine, including the vertebral bodies, paraspinal muscles, dura, nerve roots, and the spinal cord with blood. Radicular arteries are the first branches of the dorsal division of the segmental arteries. The bony spine is supplied by anterior and posterior central arteries that come directly from

Spinal cord ischemia

Compared with brain ischemia, spinal cord infarction is exceedingly rare and caused by more diverse etiologies [1]. This rarity is mainly caused by the multiple anastomoses of the spinal cord, which supply arteries. Spinal cord supplying arteries are—for unknown reasons—not significantly affected by atherosclerotic vessel wall changes. Causes for acute arterial ischemia include surgery for aortoiliac occlusive disease [6], dissection of the aorta, vasculitis, fibrocartilaginous embolism [7],

Spinal vascular malformations

Multiple different classification schemes have been proposed for spinal vascular malformations. Recently, the Bicetre group classified spinal cord arteriovenous malformations (AVMs) into three main groups [14]. The first group includes genetic hereditary lesions that are caused by a genetic disorder affecting the vascular germinal cells. Spinal cord malformations associated to hereditary hemorrhagic telangiectasia fall into this category. The second group includes genetic nonhereditary lesions

Dural arteriovenous fistulae

Spinal dural AV fistulae are the most frequent vascular malformations of the spine and account for 70% of all AV shunts of the spine [16]. They are presumably acquired lesions; however, the exact etiology is not known. Usually the disease becomes symptomatic in older men (aged 40–60 years) [17]. Most fistulae are located in the thoracolumbar region. The AV shunt is located inside the dura mater close to the spinal nerve root, where the arterial blood from a radiculomeningeal artery (ie, an

Spinal cord arteriovenous malformations

Spinal cord AVMs are fed by radicullomedullary (ie, spinal cord) feeding arteries and drained by spinal cord veins. These high-flow shunts might be intra- or perimedullarily located and can be differentiated according to their transition from artery into vein into fistulous and glomerular AVMs [30]. Glomerular AVMs (which are sometimes called plexiforme or nidus-type AVMs) are the most often encountered spinal cord AVMs, with a nidus resembling that of a brain AVM. This type of malformation

Cavernomas

Spinal cord cavernomas (or cavernous malformations) are estimated to constitute 5% of all spinal vascular malformations [46], [47]. Like their intracranial counterparts, cavernomas are discrete, lobulated, well-circumscribed, red to purple raspberry-like lesions on gross pathology. Microscopically, these lesions are composed of dilated, thin-walled capillaries that have a simple endothelial lining with variably thin fibrous adventitia indistinguishable from the lining of a capillary

Summary

The unspecific neurologic symptomatology and the variety of potentially detected vascular diseases make this clinical entity challenging for neurologists, neurosurgeons, and neuroradiologists. When spinal vascular diseases are suspected, MRI should constitute the first diagnostic modality to identify the lesion and rule out potential differential diagnoses (eg, acute cord compression, tumor, degenerative diseases of the spine, myelitis). Even with routine sequences, neuroradiologists should be

References (51)

  • S. Weidauer et al.

    Spinal cord infarction: MR imaging and clinical features in 16 cases

    Neuroradiology

    (2002)
  • R. Bammer et al.

    Diffusion-weighted MR imaging of the spinal cord

    AJNR Am J Neuroradiol

    (2000)
  • A. Gass et al.

    MRI of spinal cord infarction

    Neurology

    (2000)
  • W. Kueker et al.

    Diffusion weighted MRI of spinal cord infarction: high resolution and time course of diffusion abnormality

    J Neurol

    (2004)
  • W.T. Yuh et al.

    MR imaging of spinal cord and vertebral body infarction

    AJNR Am J Neuroradiol

    (1992)
  • G. Rodesch et al.

    Classification of spinal cord arteriovenous shunts: proposal for a reappraisal. The Bicetre experience with 155 consecutive patients treated between 1981 and 1999

    Neurosurgery

    (2002)
  • T. Krings et al.

    Spinal vascular malformations

    Eur Radiol

    (2005)
  • A. Thron

    [Spinal dural arteriovenous fistulas]

    Radiologe

    (2001)
  • R.W. Hurst et al.

    Spinal dural arteriovenous fistula: the pathology of venous hypertensive myelopathy

    Neurology

    (1995)
  • G.R. Criscuolo et al.

    Reversible acute and subacute myelopathy in patients with dural arteriovenous fistulas: Foix-Alajouanine syndrome reconsidered

    J Neurosurg

    (1989)
  • G.B. Bradac et al.

    Spinal dural arteriovenous fistulas: an underestimated cause of myelopathy

    Eur Neurol

    (1994)
  • E. Koenig et al.

    Spinal arteriovenous malformations and fistulae: clinical, neuroradiological and neurophysiological findings

    J Neurol

    (1989)
  • R.W. Hurst et al.

    Peripheral spinal cord hypointensity on T2-weighted MR images: a reliable imaging sign of venous hypertensive myelopathy

    AJNR Am J Neuroradiol

    (2000)
  • J.K. De Marco et al.

    Dural arteriovenous fistulas: evaluation with MR imaging

    Radiology

    (1990)
  • B.C. Huffmann et al.

    Spinal dural arteriovenous fistulas: a plea for neurosurgical treatment

    Acta Neurochir (Wien)

    (1995)
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