Spinal arteriovenous malformation with hypogastric blood supply Case report C. CRAIG HEINDEL, M.D., GORDON S. DUGGER, M.D., AND FAUSTINO C. GUINTO, M.D.

Departments of Surgery and Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina v' A report of a patient with a spinal arteriovenous malformation (AVM),supplied from the right hypogastric artery is presented to emphasize the importance of thorough angiographic investigation when a spinal AVM is suspected. KEYWORDS spinal arteriovenous malformation spinal cord compression 9 spinal angiography 9

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HE angiographic evaluation of spinal cord arteriovenous malformation (AVM) has been the subject of great interest in the last decade; 1-3,e,s,14,~5 however, only two papers report spinal AVM's with their arterial supply from the iliac arteries. 5,a6 A third case has been reported, but the malformation was primarily outside the spinal canal? 3 We are reporting the case of a patient whose spinal AVM was supplied from the right hypogastric artery. Case Report This 56-year-old man had a congenital skin defect over the spine at L-5. Approximately 6 months before admission he noticed that when he walked he did not feel his feet touch the ground. Subsequently he developed severe low back pain with radiation into the buttocks which was worse when he was standing. He developed diffuse weakness in the left leg and began walking in an abnormal manner because of the pain and weakness. 462

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Examination. There was a 1-cm defect in the center of a 6- to 7-cm hemangiomatous malformation centered over the spinous process of L-5. Through this defect a second layer of skin with abnormally long hair was visible. There was no drainage or tenderness. He showed spotty decreased perception of light touch and pinprick over the left leg, which seemed slightly weak. His gait was broad-based but not ataxic. Tendon reflexes were symmetrical and normal; both plantar reflexes were flexor. Myelogram revealed a vascular malformation extending from S-3 into the midthoracic region. Angiography performed by conventional selective injections into the intercostal and lumbar arteries demonstrated no lesion, but abdominal aortic and right common iliac injections revealed an AVM, fed by a single vessel originating from the lateral sacral artery (Fig. 1). Operation. The feeding artery was ligated at its point of entry into the caudal subarachnoid space, and the malformation J. Neurosurg. / Volume 42 / April, 1975

Spinal AVM with hypogastric blood supply arteriography, which also made possible the identification of the feeding vessel. The normal arterial blood supply to the spinal cord is known to include vessels from the vertebral arteries, costocervical trunk, intercostal arteries, dorsal lumbar arteries, iliolumbar branches, and lateral sacral arteries. 6,a~The relative significance and contribution of these vessels to the spinal cord blood supply varies. Most reports concerning spinal cord AVM's emphasize the importance of possible feeding arteries cephalad to the iliolumbar and lateral sacral segments. 4'9 Only three previous cases identified AVM's whose feeding arteries were below the aortic bifurcation; 13'15 however, in one of these cases the malformation was not limited to the spinal canal. We therefore wish to stress the importance of selective iliac angiography when traditional studies fail to reveal a lesion. The operative technique of ligating a feeding vessel was proposed in 1966. TM Before the introduction of this technique, many neurosurgeons declined to ligate the Fl~. 1. Subtraction film (left) and diagram (right) showing an arteriovenous malformation feeding vessel to a spinal cord AVM because with arterial supply from a branch of the internal they believed these vessels might also supply iliac artery. A small collection of residual Pantopaque can be seen at the entry of the vessel into the spinal cord. In our case the spinal cord was not infarcted following operative ligation the spinal canal. of the feeding vessel; this indicates that the arterial supply to the spinal cord was not the same as that to the vascular malformation. collapsed completely over a 15-minute period. A structure resembling abnormal Some surgeons do not agree that ligation is the best technique of treatment and propose spinal cord extended to S-2 attached to the total excision of the malformation. However, dura dorsally at this level. The skin defect was simple ligation of the single feeding vessel also excised and showed only chronic inflamcompletely alleviated the symptoms in our mation and fibrosis. Such a skin lesion is patient. commonly associated with an A V M ? 2 The patient had an uneventful postoperative course and has remained free of his References initial symptoms. His only detectable deficit has been reduced light touch sensation in the 1. Bailey WL, Sperl MP: Angiomas of the cerS-1 distribution. vical spinal cord. J Neurnsurg 30:560-568, 1969 2. DiChiro G, Doppman J, Ommaya AK: SelecDiscussion tive arteriography of arteriovenous aneurysms of spinal cord. Radiology 88:1065-1077, 1967 The incidence of AVM's is variously 3. DiChiro G, Doppman JL, Ommaya AK: quoted as being 3.3% to 11% of spinal cord Radiology of spinal cord arteriovenous tumors?' The number of these lesions idenmalformations. Prog Neurosnrg 4:329-354, tified has greatly increased since the develop1971 ment of angiographic evaluation. Wyburn4. DiChiro G, Wener L: Angiography of the Mason x6 reported 207 cases in the literature spinal cord. A review of contemporary prior to 1943, 195 cases were reported techniques and applications. J Neurosurg between 1946 and 1962, and an additional 200 39:1-29, 1973 cases were reported from 1962 to 196917 5. Djindjian R: Angiography of the Spinal Cord. Baltimore: University Park Press, 1970 after Djindjian introduced diagnosis by

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C. C. Heindel, G. S. Dugger and F. C. Guinto 6. Djindjian R: Arteriography of the spinal cord. Am J Roentgenol Raft Ther Nuel Med 107:461-478, 1969 7. Guidetti B: Surgical treatment of vascular tumors and vascular malformations of the spinal cord. Vase Surg 4:179-185, 1970 8. Houdart R, Djindjian R, Hurth M: Vascular malformations of the spinal cord. The anatomic and therapeutic significance of arteriography. J Neurosurg 24:583-594, 1966 9. Lawson TL, Newton TH: Congenital cervical arteriovenous malformations. Radiology 97:565-570, 1970 10. Lazorthes G, Gouaze A, Zodeh JO, et al: Arterial vascularization of the spinal cord. Recent studies of the anastomotic substitution pathways. J Neurosnrg 35:253-262, 1971 11. Luessenhop A J, Cruz TD: The surgical excision of spinal intradural vascular malformations. J Nenrosurg 30:552-559, 1969 12. Newman MJD: Racemose angioma of the spinal cord. Q J Med 28:97-108, 1959 13. Ochsenschl~iger VA, T~iger F, Grunbrecht C: Angioma racemosum der viszeralen Aste der

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Arteria und Vena iliaca interna. Fortschr Geb Roentgenstr Nuklearmed 112:754-758, 1970 Ommaya AK, DiChiro G, Doppman J: Ligation of arterial supply in the treatment of spinal cord arteriovenous malformations. J Neurosurg 30:679-692, 1969 Stein SC, Ommaya AK, Doppman JL, et al: Arteriovenous malformation of the cauda equina with arterial supply from branches of the internal iliac arteries. Case report. J Neurosurg 36:649-651, 1972 Wyburn-Mason R: The Vascular Abnormalities and Tumors of the Spinal Cord and Its Membranes. London, Henry Kimpton, 1943 Yasargil MG: Surgery of vascular lesions of the spinal cord with the microsurgical technique. Clin Neurosurg 17:257-265, 1969

Address reprint requests to: C. Craig Heindel, M.D., Divison of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27514.

J. Neurosurg. / Volume 42 / April, 1975

Spinal arteriovenous malformation with hypogastric blood supply. Case report.

Spinal arteriovenous malformation with hypogastric blood supply Case report C. CRAIG HEINDEL, M.D., GORDON S. DUGGER, M.D., AND FAUSTINO C. GUINTO, M...
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