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

Bikei Ryu; Tatsuki Mochizuki; Shogo Shima; Shinsuke Sato; Tatsuya Inoue; Takakazu Kawamata; Yasunari Niimi

doi:10.1007/s00062-024-01403-5

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

Clin Neuroradiol. 2024 Apr 9. doi: 10.1007/s00062-024-01403-5. Online ahead of print.

Authors

Bikei Ryu^{1

2

3}, Tatsuki Mochizuki⁴, Shogo Shima⁴, Shinsuke Sato^{5

4

6}, Tatsuya Inoue⁴, Takakazu Kawamata⁶, Yasunari Niimi⁵

Affiliations

¹ Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan. ryu.bikei@twmu.ac.jp.
² Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan. ryu.bikei@twmu.ac.jp.
³ Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan. ryu.bikei@twmu.ac.jp.
⁴ Department of Neurosurgery, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan.
⁵ Department of Neuroendovascular Therapy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, 104-8560, Tokyo, Japan.
⁶ Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan.

PMID: 38592446
DOI: 10.1007/s00062-024-01403-5

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.

Keywords: Anticoagulants; Arteriovenous malformation; Endovascular procedures; Radiology; Spinal cord vascular diseases.