Search

Objective To present treatment strategies for spinal extradural arteriovenous fistulas (AVFs) in relation to angioarchitecture. Methods A retrospective analysis comprising 14 patients treated at 2 hospitals was performed. Results The 14 AVFs included 4 cervical, 1 thoracic, and 9 lumbosacral lesions. Three key angiographic features were observed: the feeding artery, an enlarged extradural venous plexus, and intradural retrograde venous drainage. In 3 patients (3 cervical AVFs) with compressive myelopathy owing to an enlarged venous plexus, the treatment goal was mass reduction of the venous plexus. Combined endovascular and microsurgical treatments may be curative for a large venous lake with multiple feeders. No intradural procedure was required because of the absence of intradural venous drainage. In contrast, in the other 11 patients (1 cervical, 1 thoracic, and 9 lumbosacral AVFs) with congestive myelopathy owing to intradural retrograde venous drainage, the goal of treatment was occlusion of the intradural proximal vein. Microsurgery or endovascular treatment may be curative by itself for a small venous pouch with a single intradural draining vein. Extradural procedures were not required in most patients treated by microsurgery because the extradural venous plexus was small. In all 14 patients, neurologic deficits improved or stabilized, and no recurrence was noted in the follow-up period (29 months). Conclusions Spinal extradural AVFs consist of 2 subtypes—type A with intradural drainage and type B without intradural drainage—characterized by regional differences at each spinal level in angioarchitecture, causes of myelopathy, and treatment goals.

The optimal surgical procedure (direct, indirect, or combined anastomosis) for management of moyamoya disease is still debated. We evaluated the outcome of our broad area revascularization protocol, the Tokyo Daigaku (The University of Tokyo) (TODAI) protocol, analyzing the relative importance of direct, indirect, and combination revascularization strategies to identify the optimal surgical protocol.The TODAI protocol was used to treat 65 patients with moyamoya disease (91 hemispheres, including 48 in 29 childhood cases collected during 1996-2012). The TODAI protocol combined direct superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis with indirect revascularization using encephalo-myo-synangiosis (EMS) for patients ≥10 years old or indirect revascularization using encephalo-duro-arterio-synangiosis (EDAS) with EMS for patients ≤9 years old. Clinical outcome was evaluated retrospectively. Digital subtraction angiography was performed for postoperative evaluation of revascularization in 47 patients (62 hemispheres; 27 adults and 35 children). Based on the relative contribution of additional flow from each revascularization path, 4 revascularization patterns were established.The mean follow-up period was 90 months in children and 72 months in adults. Perioperative complications were seen in 4 of 48 operations in children and 1 of 43 operations in adults. Except for 1 child with recurrent transient ischemic attacks and 1 adult with intracerebral hemorrhage, the patients showed excellent clinical outcomes. Postoperative digital subtraction angiography evaluation showed that in STA-MCA anastomosis + EMS cases (34 hemispheres; 25 adults and 9 children), STA-MCA anastomosis provided greater revascularization than EMS (STA-MCA anastomosisEMS) in 7 hemispheres, the opposite was true (STA-MCA anastomosisEMS) in 14 hemispheres, an equivalent contribution to revascularization (STA-MCA anastomosis ≈ EMS) was present in 12 hemispheres, and no functioning anastomosis was present in 1 hemisphere. In cases of EDAS + EMS (28 hemispheres; 2 adults and 26 children), all hemispheres showed revascularization: EDAS was dominant to EMS (EDASEMS) in 1 hemisphere, the opposite (EMSEDAS) was true in 14 hemispheres, and EDAS was equivalent to EMS (EDAS ≈ EMS) in 13 hemispheres. EMS plus direct or indirect anastomosis is an effective surgical procedure in adults and children.The TODAI protocol provided efficient revascularization and yielded excellent results in preventing strokes in patients with moyamoya disease with very few complications. EMS had a main role in revascularization in each of the combined techniques.

Objective Surface-rendered three-dimensional (3D) 1.5-T magnetic resonance (MR) imaging is useful for presurgical simulation of microvascular decompression. This study compared the sensitivity and specificity of 1.5- and 3.0-T surface-rendered 3D MR imaging for preoperative identification of the compression vessels of trigeminal neuralgia. Methods One hundred consecutive patients underwent microvascular decompression for trigeminal neuralgia. Forty and 60 patients were evaluated by 1.5- and 3.0-T MR imaging, respectively. Three-dimensional MR images were constructed on the basis of MR imaging, angiography, and venography data and evaluated to determine the compression vessel before surgery. MR imaging findings were compared with the microsurgical findings to compare the sensitivity and specificity of 1.5- and 3.0-T MR imaging. Results The agreement between MR imaging and surgical findings depended on the compression vessels. For superior cerebellar artery, 1.5- and 3.0-T MR imaging had 84.4% and 82.7% sensitivity and 100% and 100% specificity, respectively. For anterior inferior cerebellar artery, 1.5- and 3.0-T MR imaging had 33.3% and 50% sensitivity and 92.9% and 95% specificity, respectively. For the petrosal vein, 1.5- and 3.0-T MR imaging had 75% and 64.3% sensitivity and 79.2% and 78.1% specificity, respectively. Complete pain relief was obtained in 36 of 40 and 55 of 60 patients undergoing 1.5- and 3.0-T MR imaging, respectively. Conclusions The present study showed that both 1.5- and 3.0-T MR imaging provided high sensitivity and specificity for preoperative assessment of the compression vessels of trigeminal neuralgia. Preoperative 3D imaging provided very high quality presurgical simulation, resulting in excellent clinical outcomes.