(1)
Neurosurgery Teaching Hospital, Baghdad, Iraq
This book contains some difficult questions marked with “ * “ sign.
- 1.
Spinal arteriovenous malformations (SAVM)
Incidence, the FALSE answer is:
- A.
Incidence of SAVM is about 4 % of primary intraspinal masses.
- B.
It represents one-tenth of the brain AVMs.
- C.
SAVM shows a male predominance.
- D.
SAVM usually extends over a single segment.
- E.
SAVM usually presents in the fourth or fifth decade.
- A.
The answer is D.
SAVM usually extends over four or five segments, and as a rule they are located posterior or posterolateral in the caudal spinal canal.
- 2.
SAVM
Diagnosis, the FALSE answer is:
- A.
The most common presentation for SAVM is progressive neurological deficit.
- B.
The diagnostic modality of choice for SAVM is spinal angiography.
- C.
CT scan findings are usually normal unless SAH.
- D.
The MRI usually localizes the exact fistula site.
- E.
Digital subtraction arteriography is the criterion standard modality for visualizing SAVM in real time.
- A.
The answer is D.
The MRI, in particular, allows visualization of thrombosed veins and of the spinal cord, but the exact fistula site cannot be localized.
The most common presentation for SAVM is progressive neurological deficit (subacute to chronic onset of back pain, weakness, sensory loss).
Spinal angiography: necessary to confirm the diagnosis and to identify major feeding vessels, this might be suitable for embolization and for treatment planning.
Digital subtraction arteriography allowing the assessment of high-flow versus low-flow AVMs, in addition, the location of the fistula can be visualized.
- 3.
SAVM
Types, the FALSE answer is:
- A.
Type I is dural AVF.
- B.
Type II is intramedullary or glomus AVM.
- C.
Type II is the most common type.
- D.
Type III is juvenile or combined AVMs.
- E.
Type IV is perimedullary AVF.
- A.
The answer is C.
Type I is the most common type.
Anson and Spetzler classification (1992) is most widely used.
A recently proposed classification of spinal cord vascular lesions has added extradural AVFs and conus medullaris AVMs as distinct entities.
- 4.
SAVM
Types, the FALSE answer is:
- A.
Type I is high flow, fed by radicular arteries.
- B.
Type II is high flow fed by medullary arteries.
- C.
Type III is intraparenchymal, high flow.
- D.
Type III is an enlarged form of type II that invades the entire cross section of the cord.
- E.
Type IV: perimedullary, often fed by the artery of Adamkiewicz and the anterior spinal artery.
- A.
The answer is A.
Type I: low flow (most common type, fed by radicular arteries)
Type II: intraparenchymal, high flow (fed by medullary arteries)
Type III: intraparenchymal, high flow (an enlarged form of type II that invades the entire cross section of the cord as well as the vertebral body)
Type IV: perimedullary (often fed by the artery of Adamkiewicz and the anterior spinal artery)
- 5.
SAVM
Type I, the FALSE answer is:
- A.
The most common type of malformation comprises 80–85 % of SAVM.
- B.
These lesions are most frequently found in females.
- C.
Usually presented between the fifth and eighth decades of their life.
- D.
Is dural/intradural dorsal AVFs.
- E.
A dural AVF that arises at the dural nerve root sleeve.
- A.
The answer is B.
These lesions are most frequently found in males (90 % are males).
Type 1: They are also known as intradural dorsal AVFs, angiomas racemosum, angioma racemosum venosum, long dorsal AVFs and dorsal extramedullary AVFs.
- 6.
SAVM
Type I, the FALSE answer is:
- A.
Is fed by radicular artery which forms an AV shunt located in the intervertebral foramen
- B.
Drains into an engorged spinal vein on posterior cord
- C.
Most occur spontaneously
- D.
May be of acquired etiology
- E.
Direct communication between an extradural artery and extradural vein with nidus
- A.
The answer is E.
Direct communication between an extradural artery and extradural vein with no nidus
Is fed by radicular artery which forms an AV shunt (fistula) at the dural root sleeve (located in the intervertebral foramen)
- 7.
SAVM
Type I, the FALSE answer is:
- A.
They are predominantly found in the posterior part of the lower thoracic cord and the conus.
- B.
They may be found in the conus.
- C.
Dural AVFs are predominantly located on the right side.
- D.
Type IA has single arterial feeder.
- E.
Type IB has two or more arterial feeders.
- A.
The answer is C.
Dural AVFs are predominantly located on the left side.
For type I dural AVMs, angiography must encompass all dural feeders of the neuraxis, which includes:
ICAs include the artery of Bernasconi and Cassinari
Every radicular artery including the artery of Adamkiewicz
Internal iliac arteries: for sacral feeders
- 8.
SAVM
Type I, the FALSE answer is:
- A.
15–20 % is associated with other AVMs (cutaneous or other).
- B.
Patients become symptomatic because of the venous congestion and hypertension of the spinal cord.
- C.
The absence of valves between the coronal and radicular veins decreases the venous congestion.
- D.
Presented as gradual progressive radiculomyelopathy.
- E.
Presented rarely as acute presentation and rarely bleed.
- A.
The answer is C.
The absence of valves between the coronal and radicular veins encourages venous congestion.
Patients with dural AVFs become symptomatic because the AVF creates venous congestion and hypertension resulting in hypoperfusion of the spinal cord.
- 9.
SAVM
Type I, the FALSE answer is:
- A.
Symptoms tend to be exacerbated by Valsalva maneuvers.
- B.
Foix-Alajouanine syndrome: chronic neurologic deficit in a patient with a spinal AVM without evidence of hemorrhage.
- C.
Foix-Alajouanine syndrome is due to venous thrombosis from spinal venous stasis.
- D.
Coup de poignard of Michon: onset of SAH with sudden excruciating back pain.
- E.
Gadolinium MRI has proven useful in revealing the level of the fistula before angiography.
- A.
The answer is B.
Foix-Alajouanine syndrome: acute or subacute neurologic deterioration in a patient with a spinal AVM without evidence of hemorrhage.
Foix-Alajouanine syndrome is an extreme form of spinal dural AVF that affects a minority of patients who present with a rapidly progressive myelopathy due to venous thrombosis from spinal venous stasis.
Coup de poignard of Michon: onset of SAH with sudden excruciating back pain (clinical evidence of Spinal AVM).
Gadolinium MRI has proven useful in revealing the level of the fistula before angiography. Angiography helps in treatment planning of the fistula.
- 10.
SAVM
Type I, the FALSE answer is:
- A.
The recommended treatment is surgery or embolization.
- B.
Dural AVFs can be treated with either open or endovascular ligation usually with poor results.
- C.
Open surgery is necessary if the arterial feeding vessel is impossible to access.
- D.
Open surgery is necessary if the feeding vessel supplies healthy regions of the spinal cord.
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- A.
