Neurosurgical Forum LETTER H DITOR1. DiSano MA, Cerejo R, Mays M: Acute paraparesis and sensory loss...

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J Neurosurg Pediatr Volume 21 • April 2018 439 LETTERS TO THE EDITOR Neurosurgical Forum J Neurosurg Pediatr 21:439, 2018 Steroid administration in Cognard type V dural arteriovenous fistula TO THE EDITOR: We read with interest the article by Jermakowicz et al. 2 (Jermakowicz WJ, Weil AG, Vlasenko A, et al: Cognard Type V intracranial dural arteriovenous fistula presenting in a pediatric patient with rapid, progres- sive myelopathy. J Neurosurg Pediatr 20: 158–163, August 2017). Their patient, a 14-year-old girl with 3-week history of progressive lower-extremity weakness and difficulty with ambulation, was transferred to their hospital after MRI had shown extensive changes suggesting congestive myelopathy. She had received 2 doses of dexamethasone without improvement. Immediately after arriving to their hospital, the girl showed rapid decline over 8 hours. In a patient with congestive myelopathy secondary to a dural arteriovenous (AV) fistula, the tenuous hemody- namic status can easily precipitate after relatively minor changes. 1,4,5 We have observed a recurring pattern of pa- tients with type I spinal dural AV fistula and frequent sud- den deterioration of neurological function after adminis- tration of intravenous steroids, as these patients are often first suspected to have an inflammatory condition based on early MRI findings. As stated by Nasr et al., we be- lieve that these patients’ presumed mechanism of injury is related to the increased venous hypertension and the sub- sequent venous engorgement and impairment of venous outflow from the dural shunt that results from administra- tion of corticosteroids. 3 The patient presented by Jermakowicz et al. fits our pat - tern, and we suspect this mechanism theory explains the rapid neurological deterioration otherwise unexplained in a patient who had been progressing slowly over the course of 3 weeks. Therefore, we caution against the use of ste- roids in patients with neurological dysfunction secondary to congestive myelopathy. Thomas Sorenson, BS Giuseppe Lanzino, MD Mayo Clinic, Rochester, MN References 1. DiSano MA, Cerejo R, Mays M: Acute paraparesis and sensory loss following intravenous corticosteroid administra- tion in a case of longitudinally extensive transverse myelitis caused by spinal dural arteriovenous fistula: case report and review of literature. Spinal Cord Ser Cases 3: 17025, 2017 2. Jermakowicz WJ, Weil AG, Vlasenko A, Bhatia S, Niazi TN: Cognard Type V intracranial dural arteriovenous fistula presenting in a pediatric patient with rapid, progressive my- elopathy. J Neurosurg Pediatr 20: 158–163, 2017 3. Nasr DM, Brinjikji W, Rabinstein AA, Lanzino G: Clinical outcomes following corticosteroid administration in patients with delayed diagnosis of spinal arteriovenous fistulas. J Neurointerv Surg 9:607–610, 2017 4. O’Keeffe DT, Mikhail MA, Lanzino G, Kallmes DF, Wein- shenker BG: Corticosteroid-induced paraplegia—a diagnostic clue for spinal dural arterial venous fistula. JAMA Neurol 72:833–834, 2015 5. Rain S, Udding J, Broere D: Acute clinical worsening after steroid administration in cervical myelitis may reveal a subdural arteriovenous fistula. Case Rep Neurol 8:234–242, 2016 Disclosures G.L. is a consultant for Medtronic. Response No response was received from the authors of the origi- nal article. INCLUDE WHEN CITING Published online February 2, 2018; DOI: 10.3171/2017.9.PEDS17482. ©AANS 2018, except where prohibited by US copyright law Unauthenticated | Downloaded 07/20/21 06:23 PM UTC

Transcript of Neurosurgical Forum LETTER H DITOR1. DiSano MA, Cerejo R, Mays M: Acute paraparesis and sensory loss...

Page 1: Neurosurgical Forum LETTER H DITOR1. DiSano MA, Cerejo R, Mays M: Acute paraparesis and sensory loss following intravenous corticosteroid administra-tion in a case of longitudinally

J Neurosurg Pediatr Volume 21 • April 2018 439

LETTERS TO THE EDITORNeurosurgical Forum

J Neurosurg Pediatr 21:439, 2018

Steroid administration in Cognard type V dural arteriovenous fistula

TO THE EDITOR: We read with interest the article by Jermakowicz et al.2 (Jermakowicz WJ, Weil AG, Vlasenko A, et al: Cognard Type V intracranial dural arteriovenous fistula presenting in a pediatric patient with rapid, progres-sive myelopathy. J Neurosurg Pediatr 20:158–163, August 2017). Their patient, a 14-year-old girl with 3-week history of progressive lower-extremity weakness and difficulty with ambulation, was transferred to their hospital after MRI had shown extensive changes suggesting congestive myelopathy. She had received 2 doses of dexamethasone without improvement. Immediately after arriving to their hospital, the girl showed rapid decline over 8 hours.

In a patient with congestive myelopathy secondary to a dural arteriovenous (AV) fistula, the tenuous hemody-namic status can easily precipitate after relatively minor changes.1,4,5 We have observed a recurring pattern of pa-tients with type I spinal dural AV fistula and frequent sud-den deterioration of neurological function after adminis-tration of intravenous steroids, as these patients are often first suspected to have an inflammatory condition based on early MRI findings. As stated by Nasr et al., we be-lieve that these patients’ presumed mechanism of injury is related to the increased venous hypertension and the sub-sequent venous engorgement and impairment of venous outflow from the dural shunt that results from administra-tion of corticosteroids.3

The patient presented by Jermakowicz et al. fits our pat-tern, and we suspect this mechanism theory explains the rapid neurological deterioration otherwise unexplained in a patient who had been progressing slowly over the course of 3 weeks. Therefore, we caution against the use of ste-roids in patients with neurological dysfunction secondary to congestive myelopathy.

Thomas Sorenson, BSGiuseppe Lanzino, MD

Mayo Clinic, Rochester, MN

References 1. DiSano MA, Cerejo R, Mays M: Acute paraparesis and

sensory loss following intravenous corticosteroid administra-tion in a case of longitudinally extensive transverse myelitis caused by spinal dural arteriovenous fistula: case report and review of literature. Spinal Cord Ser Cases 3:17025, 2017

2. Jermakowicz WJ, Weil AG, Vlasenko A, Bhatia S, Niazi TN: Cognard Type V intracranial dural arteriovenous fistula presenting in a pediatric patient with rapid, progressive my-elopathy. J Neurosurg Pediatr 20:158–163, 2017

3. Nasr DM, Brinjikji W, Rabinstein AA, Lanzino G: Clinical outcomes following corticosteroid administration in patients with delayed diagnosis of spinal arteriovenous fistulas. J Neurointerv Surg 9:607–610, 2017

4. O’Keeffe DT, Mikhail MA, Lanzino G, Kallmes DF, Wein-shenker BG: Corticosteroid-induced paraplegia—a diagnostic clue for spinal dural arterial venous fistula. JAMA Neurol 72:833–834, 2015

5. Rain S, Udding J, Broere D: Acute clinical worsening after steroid administration in cervical myelitis may reveal a subdural arteriovenous fistula. Case Rep Neurol 8:234–242, 2016

DisclosuresG.L. is a consultant for Medtronic.

ResponseNo response was received from the authors of the origi-

nal article.

INCLUDE WHEN CITING Published online February 2, 2018; DOI: 10.3171/2017.9.PEDS17482.©AANS 2018, except where prohibited by US copyright law

Unauthenticated | Downloaded 07/20/21 06:23 PM UTC