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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 5  |  Page : 817-818

Successful embolization of a conus medullaris arteriovenous malformation using onyx


Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi, India

Date of Acceptance22-Jul-2010
Date of Web Publication28-Oct-2010

Correspondence Address:
Sandeep Sharma
Department of Neuroradiology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.72207

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How to cite this article:
Gaikwad S B, Sharma S, Kumar S. Successful embolization of a conus medullaris arteriovenous malformation using onyx. Neurol India 2010;58:817-8

How to cite this URL:
Gaikwad S B, Sharma S, Kumar S. Successful embolization of a conus medullaris arteriovenous malformation using onyx. Neurol India [serial online] 2010 [cited 2019 Sep 20];58:817-8. Available from: http://www.neurologyindia.com/text.asp?2010/58/5/817/72207


Sir

Conus medullaris vascular malformations occupy a special place in the classification of spinal vascular malformations, because of both the location and complex angio architecture. [1] Historically, spinal vascular malformations have been treated surgically and/or by endovascular embolization with glue with an ever increasing trial of the new embolic agent Onyx, which is endowed with many desirable properties.

An 18-year-old male presented with history of pain and weakness in both the lower limbs of one year duration and bladder and bowel disturbances of nine months duration. On examination, he had mixed upper and lower motor neuron signs with power of 2/5 in both the lower limbs. MR imaging revealed T2W hyperintensity in the lower cord with multiple vascular flow voids. Spinal digital subtraction angiography revealed conus arterio-venous malformation (AVM) with supply mainly from the anterior spinal axis contributed by the right ninth dorsal (RD9) radiculomedullary artery and minor supply from the posterior spinal artery contributed by right eleventh dorsal (RD11) and right first lumbar (RL1) levels [Figure 1]. Endovascular embolization was performed via the RD9 contributor after super selective catheterization with Ultraflow micro-catheter and injecting 0.5 mL of Onyx 18 into the most distal aspect of the feeder just proximal to the first fistula with good penetration of the Onyx into the complex AVM and also filling the draining veins up to some distance achieving complete AVM obliteration with preservation of normal vessels [Figure 2]. MRI done on second day post-procedure showed complete resolution of the dilated flow voids, and T2 hyperintense signal had decreased. On day 1 post-procedure, the patient reported good subjective recovery and demonstrated mild objective improvement also.
Figure 1 :Pre-procedure imaging - (a) sagittal T2W MRI of the lumbar spine showing the edematous swollen cord and multiple tortuous dilated vascular channels present both anteriorly and posteriorly; (b, c) RD9 injection, anteroposterior view showing the enlarged radiculomedullary artery supplying the complex AVM through anterior spinal axis; (d, e) RD11 injection, anteroposterior view showing minor contribution to the conus AVM; (f, g) RL1 injection anteroposterior view showing pial contribution through posterior spinal axis

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Figure 2 :Post-embolization imaging - (a) T2W sagittal MRI (done on second post-procedure day) showing complete resolution of the abnormal vascular flow voids and decrease in the bright signal and swelling of the cord; (b) immediate post-embolization RD9 injection showing complete obliteration of the AVM with adequately filling anterior spinal axis; (c) immediate post-embolization RD11 injection also reveals patent radiculomedullary artery without any filling of the AVM; (d) immediate post-embolization RL1 injection showing patent radiculopial artery with complete obliteration of the fistula; (e) unsubtracted image of the Onyx cast

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Conus AVMs have been recently segregated into a separate class of spinal vascular malformations, and treatment can be surgical or endovascular, as they can have multiple fistulous as well as true AVM nidus components. [1] Onyx is a new non-adherent liquid embolic agent, which gives more control over the injection and can backfill multiple feeding arteries from a single arterial injection and allows for casting of complex malformations. [2] Its role in the embolization of cerebral AVMs is now considered established. [3] Few authors have reported the use of Onyx in the embolization of spinal vascular malformations [Table 1], mostly as case reports [4],[5],[6],[7] and a recent series of 17 patients by Corkill et al. Corkill et al . could achieve 82% rate of overall good clinical outcome. This is a case report of a successful embolization of conus AVM using Onyx, describing its feasibility in such lesions and also the relative simplicity of the procedure as compared to the complex nature of the conus AVM.
Table 1 :Previous reports of spinal vascular malformations treated with Onyx embolization


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  References Top

1.Spetzler RF, Detwiler PW, Riina HA, Porter RW. Modified classification of spinal cord vascular lesions. J Neurosurg Spine 2002;96:145-56.  Back to cited text no. 1
    
2.Carlson AP, Taylor CL, Yonas H. Treatment of dural arteriovenous fistula using ethylene vinyl alcohol (Onyx) arterial embolization as the primary modality: Short-term results. J Neurosurg 2007;107:1120-5.  Back to cited text no. 2
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3.Van Rooji WJ, Sluzewski M, Beute GN. Brain AVM embolization with Onyx. AJNR Am J Neuroradiol 2007;28:172-7.   Back to cited text no. 3
    
4.Molyneux AJ, Coley SC. Embolization of spinal cord arteriovenous malformations with an ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (Onyx liquid embolic system): Report of two cases. J Neurosurg (Spine 2) 2000;93:304-8.  Back to cited text no. 4
    
5.Warakaulle DR, AvivRI, Niemann D, Molyneux AJ, Byrne JV, Teddy P. Embolisation of spinal dural arteriovenous fistulae with Onyx. Neuroradiology 2003;45:110-2.Erdogan C, Hakeymez B, Arat A, Bekar A, Parlak M. Spinal dural arteriovenous fistula in a case with lipomyelodysplasia. Br J Radiol 2007;80:e98-100.  Back to cited text no. 5
    
6.Silva N, Januel AC, Tall P, Cognard C. Spinal epidural arteriovenous fistulas associated with progressive myelopathy. J Neurosurg Spine 2007;6:552-8.  Back to cited text no. 6
    
7.Corkill RA, Mitsos AP, AJ Molyneux. A single-center experience in a series of 17 patients. J Neurosurg Spine 2007;7:478-85.  Back to cited text no. 7
    


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