Spinal Vascular Disease

Overview of spinal vascular disease

Vascular malformations and abnormalities of the spinal cord are rare but important conditions that can cause significant neurological disability if untreated. Like their intracranial counterparts, spinal vascular lesions require specialist neurointerventional expertise for both diagnosis and treatment.

Spinal dural arteriovenous fistulas (SDAVF)

Spinal dural arteriovenous fistulas are the most common spinal vascular malformation. They occur when an abnormal connection forms between a radicular artery and a radicular vein within the dural sleeve of a spinal nerve root, leading to raised venous pressure in the spinal cord (venous congestion myelopathy). Left untreated, progressive cord injury leads to irreversible neurological damage.

Symptoms develop insidiously and include:

• Progressive weakness in the legs
• Sensory disturbance — numbness, tingling, or pain in the legs
• Bladder and bowel dysfunction
• Gait difficulty

The condition is frequently misdiagnosed as degenerative spinal disease, multiple sclerosis, or peripheral neuropathy. MRI of the spine may show cord signal change and engorged perimedullary vessels, but catheter spinal angiography is required for definitive diagnosis.

Treatment is by endovascular embolisation or surgical disconnection of the fistula. Early treatment is associated with stabilisation or improvement of neurological deficits.

Spinal AVMs

Spinal arteriovenous malformations (AVMs) are abnormal tangles of blood vessels within or adjacent to the spinal cord. They are classified by location (intramedullary, perimedullary, or extradural) and by their arteriovenous architecture. Spinal AVMs may present with:

• Haemorrhage — sudden onset of severe back pain and neurological deficit
• Progressive neurological deterioration — from venous congestion or cord compression
• Intermittent neurological symptoms — worsened by exercise (Foix-Alajouanine syndrome in some perimedullary fistulas)

Treatment depends on the type and location of the AVM and may involve endovascular embolisation, microsurgery, or stereotactic radiosurgery, often in combination.

Spinal cavernous malformations

Cavernous malformations (cavernomas) are clusters of abnormally enlarged blood vessel channels within the spinal cord that can bleed repeatedly, causing episodic neurological deterioration. They are typically visible on MRI as a characteristic "popcorn" appearance. Treatment is surgical in selected symptomatic cases.

Spinal angiography

Catheter-based spinal angiography is the gold-standard investigation for spinal vascular malformations. It provides dynamic information about arteriovenous shunting and the angioarchitecture of lesions that cannot be obtained from cross-sectional imaging alone, and is essential for treatment planning. The procedure is performed under general anaesthesia or sedation and typically takes 2–4 hours depending on the number of vessels that require interrogation.

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