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Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain

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Abstract

Background and Purpose

The prognosis of untreated spinal arteriovenous malformations (SAVMs) is poor. Embolization plays an important role in the management of intramedullary SAVMs. Delayed aggravation due to spinal venous thrombosis following successful embolization has been reported; however, perioperative management strategies to prevent thrombosis have not been explored. We present our single-center experience of SAVM embolization and perioperative management, including anticoagulation.

Material and Methods

We retrospectively evaluated 18 patients with SAVMs who underwent transarterial embolization. Perioperative anticoagulation therapy was administered to selected patients. We compared the characteristics of the patients, including perioperative management procedures, between those with and without postoperative worsening following embolization.

Results

Acute postoperative worsening within 1 week occurred in 4 (22.2%) patients. Of these, immediate worsening was observed in one patient as a procedure-related complication. Delayed worsening after 24 h was observed in 3 patients, caused by delayed venous thrombosis with severe back pain. Rescue anticoagulation for delayed worsening improved symptoms in two patients. A comparison between patients with and without acute postoperative worsening revealed significant differences in age (median 46.5 vs. 26.5 years, p = 0.009) and the presence of postoperative back pain (75.0% vs. 0%, p = 0.005); however, there was no significant difference in use of selective anticoagulation (p = 0.274).

Conclusion

The results of this study suggest that SAVM embolization can cause acute worsening due to postoperative venous thrombosis with severe back pain, which may be reversed by anticoagulation therapy. Back pain is an important finding that suggests venous thrombosis, and anticoagulation should be urgently administered.

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Authors and Affiliations

  1. Department of Neuroendovascular Therapy, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan

    Bikei Ryu, Shinsuke Sato & Yasunari Niimi

  2. Department of Neurosurgery, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan

    Bikei Ryu, Tatsuki Mochizuki, Shogo Shima, Shinsuke Sato & Tatsuya Inoue

  3. Department of Neurosurgery, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan

    Bikei Ryu, Shinsuke Sato & Takakazu Kawamata

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  1. Bikei Ryu
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Contributions

Bikei Ryu: conceptualization, methodology, formal analysis, investigation, data curation, writing- original draft preparation. Tatsuki Mochizuki, Shogo Shima, Shinsuke Sato and Tatsuya Inoue: data curation, investigation, writing- reviewing and editing. Takakazu Kawamata: writing- reviewing and editing, supervision. Yasunari Niimi: conceptualization, methodology, data curation, writing- reviewing and editing, supervision.

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Correspondence to Bikei Ryu.

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Conflict of interest

B. Ryu, T. Mochizuki, S. Shima, S. Sato, T. Inoue, T. Kawamata, and Y. Niimi declare that they have no competing interests.

Ethical standards

All procedures performed in studies involving human participants or on human tissue were in accordance with the ethical standards of the Institutional Research Committee (Saint Luke’s International Hospital, No. 19-R200) and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. The need for written informed consent was waived due to the retrospective design of the study.

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Data Availability

All relevant data supporting the results of the present study are included within the article and its Supplementary Information and can be obtained from the corresponding author upon reasonable request.

Supplementary Information

Supplementary Fig. 1.

Flow chart of the postoperative clinical course.

Supplementary Fig. 2.

Postoperative changes in the modified Aminoff-Logue scale (A–D) Time course of mALS score evaluated preoperatively, perioperatively, and 3 and 6 months after treatment. The comparison between patients with acute postoperative worsening and without worsening revealed a trend toward greater severity of preoperative mALS in the acute worsening group, without statistical significance. (A) Total mALS. (B) mALS-Gait. (C) mALS-Urinary incontinence. (D) mALS‑D (fecal continence/constipation). mALS, modified Aminoff-Logue scale; M, months.

Supplementary Video 1. N‑butyl-2-cyanoacrylate injection (25%) from the posterior spinal artery.

Supplementary Video 2. N‑butyl-2-cyanoacrylate injection (37%) from the posterior spinal artery.

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Ryu, B., Mochizuki, T., Shima, S. et al. Perioperative Management of Spinal Arteriovenous Malformation Embolization: Delayed Venous Thrombosis and Implications for Severe Back Pain. Clin Neuroradiol (2024). https://doi.org/10.1007/s00062-024-01403-5

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