Interactive Transcript
0:01
This is the quandary that we sometimes have
0:03
with evaluation for patients who have vascular
0:06
malformations of the spinal canal.
0:09
This is a patient who had
0:10
a thoracic myelopathy.
0:12
As we scroll the images on T2-weighted scans,
0:16
we see what appears to be prominent vessels on
0:19
the surface of the spinal cord, which are
0:21
selective in the lower thoracic region.
0:24
We don't see them going superiorly
0:27
above the T6 level.
0:29
This is present both on the STIR image, as well
0:32
as on the traditional spin echo T2-weighted scan.
0:37
Lots of prominent vessels in the intradural
0:39
extramedullary space.
0:41
Well, it is said that patients who have vascular
0:45
malformations, like a dural AV fistula,
0:48
if they're symptomatic,
0:50
they almost always will have abnormal
0:52
signal intensity in the spinal cord.
0:54
In this case,
0:55
both on the STIR and the T2-weighted scan,
0:58
the spinal cord signal is normal.
1:00
So what will we do?
1:01
Is this a vascular malformation that just
1:04
hasn't gotten to the level of venous
1:05
congestion that the cord is bright?
1:08
Or is this normal variation blood vessels
1:11
on the surface of the spinal cord?
1:13
In this situation,
1:13
we would obtain postgadolinium-enhanced scans
1:17
and in this particular patient,
1:20
that was not performed.
1:22
But the patient did go on to spinal arteriography
1:25
and it was normal.
1:27
So again,
1:28
the adage is that if it is a symptomatic
1:31
spinal dural AV fistula,
1:33
you should see abnormal signal intensity
1:35
within the spinal cord.
1:37
And if you don't see abnormal
1:39
signal in the spinal cord,
1:40
then I would be a little bit more cautious
1:43
about calling it a vascular malformation.
1:46
So again, word to the wise,
1:48
do the postgadolinium-enhanced
1:49
scans. And also, if that is equivocal,
1:54
try your spinal arterioven...
1:56
uh, your spinal angiogram.
1:57
Your dynamic injection of contrast
2:00
for a spinal angiogram.
2:01
So, what's the difference between this case
2:04
and the previous example I demonstrated?
2:07
Here we have a patient that also
2:09
has a thoracic myelopathy.
2:10
The patient is 69 years old.
2:13
And we again see what appear to be a lot of
2:16
prominent squiggles on the surface
2:18
of the spinal cord.
2:19
You'll notice that they are predominantly
2:21
on the posterior aspect,
2:22
although more anteriorly here.
2:24
And there is also associated cord signal abnormality.
2:29
So here is the demonstration of the intradural
2:32
intramedullary cord signal abnormality, in
2:36
associated with prominent vessels in the
2:40
intradural extramedullary location
2:43
that are present on STIR imaging.
2:47
Little squiggles. As well as post contrast imaging
2:53
where we see them as little dots of contrast enhancement
2:56
in the intradural extramedullary compartment.
3:00
So the difference between this case and the
3:02
previous case is that the vascular abnormality that we see,
3:06
or the blood vessels, are extending all the way
3:09
up to the cervical region and down
3:12
to the lower thoracic region.
3:15
It is associated with abnormal cord
3:17
signal abnormality. And in fact,
3:20
on the post gadolinium-enhanced scans,
3:23
we see that there is is kind of a faint
3:26
enhancement of the cord itself.
3:28
This is secondary to that venous congestion
3:31
that I mentioned previously.
3:32
I'm just going to magnify that and compare it
3:36
to the pre gadolinium T1-weighted
3:38
images where, again,
3:40
you see that there is that faint enhancement
3:44
in the conus medullaris.
3:47
So this is a patient who had a dural
3:50
arteriovenous fistula.
3:51
Type 1 spetzler classification,
3:54
associated with abnormal cord
3:56
signal myelopathy, as well as draining
4:00
veins in the intradural extramedullary
4:02
compartment and cord signal abnormality,
4:05
intradural intramedullary. So, again,
4:08
this is a patient that gets referred
4:10
to conventional arteriography,
4:11
at least at my institution.
© 2024 Medality. All Rights Reserved.