title: Surgical management of combined intramedullary arteriovenous malformation and perimedullary arteriovenous fistula within the hybrid operating room after five years of performing focus fractionated radiotherapy: case report.
abstract: Perimedullary arteriovenous fistula (AVF) shunts occur on the spinal cord surface and can be treated surgically or by endovascular embolization. In contrast, the nidus of an intramedullary arteriovenous malformation (AVM) is located in the spinal cord and is difficult to treat surgically or by endovascular techniques. The benefits of radiotherapy for treating intramedullary AVM have been published, but are anecdotal and consist largely of case reports. We present a case of combined cervical intramedullary AVM and perimedullary AVF which received surgical treatment within a hybrid operating room (OR) after 5 years of focus fractionated radiotherapy. A 37-year-old male presented with stepwise worsening myelopathy. Magnetic resonance imaging and spinal angiography revealed intramedullary AVM and perimedullary AVF at the C3 to C5 levels. In order to reduce nidus size and blood flow, we first performed focal fractionated radiotherapy. Five years later, the lesion volume was reduced. Following this, direct surgery was performed by an anterior approach using corpectomy in the hybrid OR. The spinal cord was monitored by motor-evoked potential throughout the surgery. Complete obliteration of the fistulous connection was confirmed by intraoperative indocyanine green video-angiography and intraoperative angiography, preserving the anterior spinal artery. We conclude that surgical treatment following focal fractionated radiotherapy may become one strategy for patients who are initially deemed ineligible for endovascular embolization and surgical treatment. Furthermore, the hybrid OR enables safe and precise treatment for spinal vascular disorders in the fields of endovascular treatment and neurosurgery.
authors.affiliation: Department of Neurosurgery, Hokkaido University Graduate School of Medicine.
authors.forename: Masayuki
authors.initials: M
authors.lastname: Gekka
authors.forename: Toshitaka
authors.initials: T
authors.lastname: Seki
authors.forename: Kazutoshi
authors.initials: K
authors.lastname: Hida
authors.forename: Toshiya
authors.initials: T
authors.lastname: Osanai
authors.forename: Kiyohiro
authors.initials: K
authors.lastname: Houkin
mesh_terms: D000328:Adult; D000792:Angiography; D001165:Arteriovenous Malformations / Q000175:diagnosis / Q000532:radiotherapy* / Q000601:surgery*; D020785:Central Nervous System Vascular Malformations / Q000175:diagnosis / Q000532:radiotherapy* / Q000601:surgery*; D003131:Combined Modality Therapy; D019583:Dose Fractionation, Radiation; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D019233:Retreatment; D013116:Spinal Cord / Q000098:blood supply*