SUMMARY:A 68-year-old woman presenting with progressive paraparesis was diagnosed with an AVF involving a previously fractured L1 vertebral body on which feeders from multiple segmental arteries converged. The most distinctive feature in our patient was that the fistula was located in the vertebral body. Transarterial embolization of the segmental arteries with coils and glue resulted in total obliteration of the fistula, which in turn resulted in symptom improvement.ABBREVIATION: AVF ϭ arteriovenous fistula E pidural or paraspinal AVF is very rare, and few cases have been reported in the literature.1-4 It is not a well-known entity, and it is not always easy to distinguish an epidural AVF from a dural AVF when reflux into the perimedullary veins is present. Although intradural reflux is rare in paravertebral shunts, it may show angiographic findings similar to those of a dural AVF and venous hypertension of the spinal cord.2 We report a case of trauma-related intraosseous fistula directly draining through the L1 basivertebral vein into the epidural, paraspinal, and perimedullary venous plexuses. Case ReportA 68-year-old woman presented with a 5-month history of a tingling sensation in both legs and a 2-month history of gradually progressive paraparesis. In addition, she also had a 9-year history of back pain after falling from a ladder.Neurologic examination revealed that she was unable to walk steadily and had paraparesis (grade IV/V). Sensory examination demonstrated paresthesia and hypesthesia of the perianal area and both lower extremities, symmetrically. Urinary retention and fecal incontinence were noted. Her deep tendon reflexes were slightly increased in the bilateral lower extremities. Pathologic reflexes, such as ankle clonus and Babinski sign, were positive.Engorged intraosseous and perimedullary veins accompanying cord signal-intensity changes were detected on CT scans (Fig 1A, -B) and MR images (Fig 2). Spinal angiography showed intraosseous fistulas and multiple feeders from bilateral L1 and L2 and right T12 segmental arteries (Fig 3).She was diagnosed with trauma-related epidural or paraspinal AVF. We confirmed that the venous flow drained mainly via the intraosseous L1 basivertebral vein into the epidural venous plexus on the left in a downward direction; then, the flow drained into the left paravertebral veins on the spinal angiography. We tried embolization through the left femoral vein but failed to find the connection between the epidural or paravertebral vein and the left femoral vein or inferior vena cava. Transarterial embolization was selected as the treatment technique.The muscular branches in each segmental artery were protected by coils due to the delay of wound healing, which might have been caused by occlusion of superficial arteries during embolization. Multiple feeders were occluded, including the venous sac, with 33% glue-that is, a mixture of n-butyl cyanoacrylate (Histoacryl; B. Braunn, Melsungen, Germany) and iodized oil (Lipiodol; Guerbet, Aulnay-Sous-Bois, France) at a ratio...
The extent of carotid artery atherosclerosis correlates with increased plasma concentrations of total cholesterol (TC) and low-density lipoprotein-cholesterol (LDL-C) and with a decreased plasma concentration of high-density lipoprotein-cholesterol (HDL-C). However, emerging data suggest that a triglyceride (TG):HDL-C ratio may be a better predictor of vascular risk than the traditional lipid measures such as TC and LDL-C. The purpose of this study was to evaluate the association between TC, LDL-C, TG, HDL-C, and the TG:HDL-C ratio with steno-occlusive disease in the intracranial cerebral arteries. We analyzed the records of 361 stroke-free subjects who underwent brain magnetic resonance angiography as part of their voluntary health checks. The presence of a steno-occlusive lesion in the basilar artery (BA) and in the horizontal portion of the middle cerebral artery (MCA) was assessed using brain 3D time of flight magnetic resonance angiography. All patients had fasting lipid panels drawn. We categorized serum lipid indices into quartiles and logistic regression analyses were performed. No serum lipid index was associated with the prevalence of MCA disease; TC, LDL-C, and HDL-C concentrations were not correlated with the prevalence of BA disease. A TG concentration in the third quartile compared with the lowest quartile was associated with increased prevalence of BA disease. The TG:HDL-C ratios in the upper three quartiles compared with the lowest quartile were associated with increased prevalence of BA disease. In conclusion, the TG:HDL-C ratio is more highly associated with the intracranial steno-occlusive disease than any standard lipid measure.
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