Twenty consecutive patients with spinal arteriovenous malformations (AVMs) were found to have either a progressive, remitting or remitting‐progressive course of disease. A characteristic progressive neurological decline was observed in 11 patients with dural fistulas and a similar decline was seen in 5 of the 9 patients with intradural AVMs. In addition to paraparesis and mixed sensory disorder, which ascended to a level of about T10, areas with spared sensation were occasionally found below this level. All cases with this progressive longitudinal myelopathy showed radiological evidence of a dilated medullary venous plexus. All patients were treated by embolization with only a low frequency of complications. Follow‐up data verified a significant improvement of motor and sensory function, mainly during the first year after embolization. Cases with progressive neurological decline (dural and intradural AVMs) stopped deteriorating or improved and cases with a history of acute incidents (intradural AVMs) probably run less risk of acute deterioration.

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The overall function, pain and mood disturbances of 19 patients with spinal arteriovenous malformations (AVM), treated by embolization between 1983 and 1988, were studied. The after‐care had taken place in different hospitals and clinics. The patients demonstrated markedly poorer physical function (Sickness Impact Profile) and poorer psychological well‐being (Mood Adjective Check List) than control population samples and a comparison group of traumatic incomplete paraplegies. The degree of decrease of mood levels implied possible depressive disorder (Hospital Anxiety and Depression scale) in 16% of the patients and differed from that of the paraplegic comparison group. Furthermore, the AVM patients reported more disturbance of their family and social life than the paraplegics and they were more seldom gainfully employed. Patients recorded a wide range of pain scores, significantly worse than the paraplegics, and their pain was closely linked to overall quality of life (QL) perception. The QL scores were consistently related to all measures of functional and emotional status, but no connection with neurological lesion levels or medical complications was found. Specialised programmes after embolization, such as those offered in spinal injury units, would appear appropriate for AVM patients to improve their physical functioning and to provide a more rewarding social life.

A recent case of Lipiodol UltrafluidR embolism to the brain is reported. Pathogenetic concepts involving right-to-left shunts, and lympho-venous shunts with pulmonary capillary overloading a r e reviewed. Ili addition, it is suggested that a local disturbance in cerebral circulation d u e to a cava superior syndrome may contribute to the severe cerebral symptoms. The purpose of this report is t o add a recent case t o t h e previously reported, t o briefly review t h e literature, a n d to discuss predisposing factors. CASE REPORTR.S., a 37-year-old seaman, was admitted in September 1974 because of swollen lymph nodes in the neck. In 1965 he had undergone a thoracotomy because of a vena cava superior syndrome thought to have a traumatic origin. A fibrotic-constricted part of the vein was replaced by a teflon prosthesis, but was later obliterated by thrombosis. An extensive network of anastomotic veins developed on the upper arms, thorax and abdomen, and his facial congestion and dyspnoea diminished. Still, his respiratory function was somewhat restricted, perhaps due to postoperative adherences. In addition, he had alcohol problems. In 1972 he had an episode of delirium tremens in the tropics, and durihg 1973 he suffered some minor head injuries. During periods of alcohol abstinence he had a few epileptic fits.At admission, large lymph nodes were found on both sides of the neck, but not in other areas. A subcutaneous network of venous anastomoses was seen on the thorax, shoulders and upper abdomen. A few hours after the investigation the patient was found lying with his eyes open but unable to follow his surroundings, and unresponsive apart from answering "yes." He was incontinent and febrile (39.2O C). A neurological examination disclosed a sucking reflex, slightly dilated pupils with a sluggish reaction to light, a left gaze paralysis and a nystagmus elicited by right gaze. The optic fundi were normal without signs of embolization. The upper extremities were paralytic. Tendon reflexes were normal in the arms, brisk in the lower extremities. A Babinski sign was found bilaterally. The CSF composition was normal but the lumbar pressure was possibly elevated, 22 cm H20. There were no signs of pulmonary embolism. The arterial blood gases were normal. The following day the chest x-ray was normal. The middle portion of the thoracic duct was still filled with contrast medium (Fig. 1). A film of the abdomen showed, besides the remaining contrast in lumbar and iliac lymph nodes, a remarkably good delineation of the contours of the kidneys. In retrospect this was also demonstrable in the films taken a few hours after the Lipiodol UltrafluidR injection (Fig. 2). We believe that it was due to an accumulation of contrast medium in the cortex of the kidneys. No chylomicrons were demonstrated in the urine. A lateral view of the skull disclosed no visible contrast deposits. Repeated examinations of coagulation factors and platelets did not show any signs of disseminated intravascular coagulation. A diagnosis of cerebral contra...