Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

49

Share

Download to read offline

SPINAL CORD ARTERIOVENOUS MALFORMATIONS

Download to read offline

Spinal avm

Related Books

Free with a 30 day trial from Scribd

See all

Related Audiobooks

Free with a 30 day trial from Scribd

See all

SPINAL CORD ARTERIOVENOUS MALFORMATIONS

  1. 1. SPINAL AVM – CLASSIFICATION AND MANAGEMENT 06-Jan-16 1
  2. 2. Spinal Cord Vascular Malformations It represent a heterogeneous group of non-neoplastic vascular abnormalities Spinal arteriovenous malformation (AVM) is an abnormal tangle of arteries and veins in which the arteries feed directly into the veins with abnormal intervening capillary bed. AV fistula (AVF): direct communication between artery & vein AV malformations (AVMs): multiple complex communications Nidus: the core of an AVM that appears angiographically and anatomically as a conglomeration of vessels because of the superimposition of arteries and veins. 06-Jan-16 2
  3. 3. Incidence  Rare cause of neurologic dysfunction  5% of all intraspinal pathology  Occur throughout the spine  Affect any age group, majority: 30-50  Better diagnosis and management with improved techniques of spinal angiography, MRI, MRA and endovascular surgery O`Toole and McCormick. Chapter 83: Vascular Malformations of the Spinal Cord. Rothman-Simeone The Spine. 5th Edition 06-Jan-16 3
  4. 4. HISTORY AND CLASSIFICATION  Classification of spinal AVM has evolved with the technology available to study them.  Earliest studies were based on postmortem examinations.  1888, Gaupp described them as “hemorrhoids of the pia mater spinalis”.`  In 1914, Charles Elsberg performed the first successful operation on a spinal cord AVM.  1925 – Sargent: classified 19/21 cases as venous angiomas  1943 – Wyburn Mason classified AVMs into histological groups arteriovenous angiomas and purely venous angiomas(more common) 06-Jan-16 4
  5. 5.  Baker –layton in 1967 classified AVM s into 3 categories: Type 1 - single coiled vessel type Type 2 - Glomus AVM Type 3 - juvenile AVMs • 1977 – Kendall and logue identified AVFs in the dural sleeve of spinal nerve roots which were consistent with single coiled vessel type of AVMs. HISTORY AND CLASSIFICATION 06-Jan-16 5
  6. 6. HISTORY AND CLASSIFICATION  Two additional advances in the last 25years 1977 – Recognition by Djindjian that some intradural lesions that were previously considered AVMs of the spinal cord are actually simple AVFs in the pia(Perimedullary AVFs) Recognition of cavernous angiomas 06-Jan-16 6
  7. 7. Classification: Berenstein A(1999)  Spinal cord vascular malformation Isolated - AVMs and Av fistulas Multiple – Metameric (Cobb syndrome and other associations) and non metameric (Rendu –Osler – weber syndrome) • Spinal cord telangiectasias • Cavernomas 06-Jan-16 7
  8. 8. Classification: Anson, Spetzler(1992)  Most widely accepted. 4 types Type 1: AV Fistula located between a dural branch of the spinal ramus of a radicular artery and an intradural medullary vein Type 2 : Intramedullary glomus malformation with a compact nidus within the substance of the spinal cord Type 3: Juvenile or combined AVMs -extensive AVM often extending to the vertebra or paraspinal tissues. 06-Jan-16 8
  9. 9. Type 4 : Intradural perimedullary arteriovenous fistula  A – simple fistula fed by a single arterial branch. B – Intermediate sized fistula with multiple dilated arterial feeders C – Large perimedullary fistula with multiple giant arterial feeders. Classification: Anson, Spetzler(1992) 06-Jan-16 9
  10. 10. MODIFIED CLASSIFICATION OF SPINAL CORD VASCULAR LESIONS 1. NEOPLASTIC VASCULAR LESION • Hemangioblastoma • Cavernous malformation 2. SPINAL ANEURYSM 3. AVF : Extradural Intradural • Ventral (Small/Medium/Large shunt) • Dorsal (Single/Multiple feeder) 4 AVM • EXTRADURAL-INTRADURAL • INTRADURAL • CONUS MEDULLARIS Spetzler and Detwiler 06-Jan-1610
  11. 11. Arterial Anatomy 1. Anterior spinal artery:  Arises from the fusion of a contribution from each of the vertebral arteries  Supplies the ventral 2/3 of the cord  Important contribution to the ASA is from the artery of Adamkiewicz, which may arise anywhere from T8 to L1, more often on the left side.  The anterior spinal axis in the anterior commissure of the spinal cord and gives rise to perforators throughout its length. 2. Paired posterior spinal arteries:  run the length of the spine  supply the posterior 1/3 of the cord 06-Jan-16 11
  12. 12. Arterial Anatomy 3. At each segmental level: a dorsal ramus of the segmental artery enters the intervertebral foramen and gives rise to 3 branches:  Dural branch: to dura  Radicular branch: to nerve root  Medullary branch:  Augments the flow to the anterior spinal artery  During the 3rd stage of fetal development, most of the medullary branches involute  distal portion of the cord relatively ischemic  Somewhere between T8 & L2, especially on the left: the medullary branch does not involute and becomes the artery of Adamkiewicz 06-Jan-16 12
  13. 13. Arterial Anatomy 06-Jan-16 13
  14. 14. Venous Anatomy  Coronal venous plexus:  A plexus on the cord surface  Formed by coalescence and anastomosis of radial veins  Epidural venous plexus:  At segmental levels, medullary veins leave the coronal plexus and exit the intervertebral foramen to join the epidural plexus  The plexus communicates with the venous sinuses of the cranial dura  It drains into the ascending lumbar veins and the azygous venous system 06-Jan-16 14
  15. 15. Pathophysiology of Symptoms  Depends on the type of the AVM High-flow: Ischemia Hemorrhage Slow-flow: Venous congestion Mechanical compression of the spinal cord and roots 06-Jan-16 15
  16. 16. CLINICAL PRESENTATION The clinical signs are due to: (1) SAH; (2) haematomyelia; (3) steal into AVF/AVM; (4) venous hypertension; (5) thrombosis of draining vein, (6) pressure of aneurysm, venous or arterial, true or false; (7) arachnoiditis; (8) syringomyelia and (9) Foix-Alajouanine syndrome, a result of chronic venous ischaemia of the spinal cord. 06-Jan-16 16
  17. 17. Dural Arterio- Venous Fistula 06-Jan-1617
  18. 18. Type I (Dural AV Fistula)  The most common type  60% of spinal AVF/AVM  Single AV connection within the dura of the nerve root sheath  Results in dilated arterialized coronal venous plexus 06-Jan-16 18 Dural AV Fistula Medullary vein
  19. 19. Spinal Dural Arteriovenous Fistula  Represent at least 35% of all spinal vascular malformations in large series, although some estimates range as high as 80%  Most commonly occur at thoracolumbar levels, usually between T5 and L3  It represents an AV shunt that occurs within dural covering of spinal cord, below and medial to the pedicle.  Located adjacent to intervertebral foramen or within dural root sleeve, with arterial supply arising from dural branch of radicular artery.  An intradural vein drains the shunt directly into the pial veins of the cord J Neurosurg 1983;59:1019-1030.06-Jan-16 19
  20. 20. Pathophysiology  AV shunting result in venous engorgement and venous hypertension involving the spinal cord (Venous congestion, steal phenomenon, ischemia and hemorrhage)  Most often, no direct arterial supply to the spinal cord itself originates from the radicular artery feeding an SDAVF.  In 10% to 15% of cases, however, SDAVF is fed by a radicular artery that also supplies spinal cord via a radiculomedullary or radiculopial branch Radiology 1985;154:687-689. 06-Jan-16 20
  21. 21. SUBACUTE NECROTIZING MYELOPATHY VENOUS HYPERTENSIVE MYELOPATHY & Cord edema, stagnation of bloood flow , blood – CNS disruption Intramedullary vasodialation, Loss of autoregulatory capacity Tissue perfusion ( hypoxia ) Intramedullary arteriovenous pressure gradient Venous engorgement & venous hypertension Increased pressure & engorgement of pial veins Intradural vein  Pial veins PATHOPHYSIOLOGY 06-Jan-1621
  22. 22. Clinical presentation  Most common spinal vascular anomaly in older adult, afflicts males in 80% to 90% of cases  Presents after the fourth or fifth decade;  Chronic progressive myelopathy leads to progressive lower extremity weakness, often characterized by both UMN & LMN signs.  Localized or radicular back pain, bowel, bladder, and sexual dysfunction -Often exacerbation by excersise  Claudication pain is a common presentation in dural AVF. Claudication pain and neurological deficit may be worsened by a heavy meal  Lead to paraplegia within 2 – 4 years.  Never bleeds.  15% of the patients have rapid neurological worsening and is called  Foix alajouanine syndrome and is due to venous congestion and should be treated immediately 06-Jan-16 22
  23. 23. Imaging 06-Jan-16 23 Anteroposterior (A) and lateral (B) lumbothoracic spine radiographs reveal medial erosion of the pedicles (A, arrows) and scalloping of the posterior aspect of several vertebrae (B).
  24. 24. MRI  Conus and lumbar enlargement of the cord are almost uniformly affected; however, abnormal signal may extend into upper thoracic cord levels – Non specific.  Hallmark of diagnosis is demonstration of dilated pial veins of cord, most commonly along dorsal surface.  MR reflect pathophysiologic features of SDAVF including cord edema and venous hypertension with engorgement of the pial veins  Ischemia and venous infarct can occur. 06-Jan-16 24
  25. 25. 06-Jan-1625
  26. 26. 06-Jan-16 26
  27. 27. SPINAL ANGIOGRAPHY : •AVF shunt below or medial to the pedicle . •The draining vein is almost 10 times larger than feeding artery. •The arterial flow is slow . •Recently, the use of time-resolved imaging of contrast kinetics (TRICKS) has improved the detection rate and accuracy of MRA and DSA for diagnosis and localisation is often unnecessary. 06-Jan-1627
  28. 28. Type II (Glomus AVMs)  Analogous to intracranial AVMs  Tightly packed nidus of dysmorphic arteries and veins in direct communication w/o capillary bed; over a short segment of the spinal cord  The nidus may be completely or partially intramedullary  Typically lie in the anterior half of the spinal cord and are supplied by one or two medullary arteries via the anterior spinal artery  Usually at the cervicothoracic junction 06-Jan-16 28
  29. 29. glomus type •Compact nidus •Intramedullary • Multiple branches of ASA & PSA •High pressure •Relatively low resistance •High blood flow •Aneurysm common 06-Jan-1629
  30. 30. Pathophysiology of Type II  Vascular steal mechanism: High-flow lesion; AVM nidus acts as a low-resistance sump siphoning blood away from the surrounding normal spinal cord  Dysmorphic vessels susceptible to hemorrhage  Mass effect: myelopathy or radiculopathy 06-Jan-16 30
  31. 31. Clinical Presentation of Type II  Childhood or adult years  Acute presentation from subarachnoid or intramedullary hemorrhage is most common  Acute onset of severe neck or back pain “coup de poignard” approximates the level of AVM: typically the first symptom of AVM hemorrhage 06-Jan-16 31
  32. 32. Juvenile Spinal AVM Intramedullary & extramedullary +/- extraspinal extension 06-Jan-1632
  33. 33. Vascular anatomy – Intradural AVMs Juvenile type (TYPE 3):  These lesions are fed by multiple enlarged medullary arteries via the anterior and posterolateral spinal arteries and may have a voluminous nidus that completely fills up the thecal sac.  The nidus also has intervening neural tissue.  These may frequently involve vertebrae and paraspinal tissues .  These lesions are high-flow AVMs; a spinal bruit may indicate their presence. 06-Jan-16 33
  34. 34. JUVENILE SCAVM EXTRADURAL-INTRADURAL AVM 06-Jan-1634
  35. 35. SYMPTOMS 06-Jan-16 35 • MALE or FEMALE • Age : 2 or 3 decade Nearly 50 % < 16 years . • 30 %  weakness as initial symptoms • 20 %  Back pain at onset . • Over 70 %  develop sensory symptoms • 50 %  Spinal hemorrhage • Bladder & bowel involvement
  36. 36. •Slow flow AVM  Myelopathic symptoms . • High flow AVM  Bleed: •HEMORRHAGE : •SAH OR intramedullary bleed , •High mortality ( 30 % ) •High rate of bleeding (40 % within first year ) ACUTE MEDULLARY SYNDROME . May progress rapidly , or there may be partial remissions. Prognosis : Poor . 06-Jan-1636
  37. 37. Imaging  Flow voids representing enlarged arterial feeding vessels and intramedullary nidus are well seen  Haemorrhage is also seen in various stages.  Nonhemorrhagic intramedullary signal abnormality adjacent to the nidus and most likely indicates gliosis, edema, or areas of cord infarction.  Extension of nidus into extramedullary structures, paraspinal soft tissue structures, is also well seen on MR  Angiographic evaluation of delineation of all feeding vessels, aneurysms, locating the nidus within the cord, and mapping the size and location of draining veins. 06-Jan-16 37
  38. 38. IMAGING : AVMs 06-Jan-16 38  MRI : best noninvasive modility  Flow voids  enlarged arterial feeding vessels  Intramedullary nidus  Recent / remote intramedullary hemorraghe  T2W Hyperintensity : gliosis, edema, infarction  Draining veins : • Flow voids, • Ectasia , • Mass effect, • Thrombosis  Intramedullary contrast enhancement
  39. 39. 06-Jan-16 39 Juvenile-type intramedullary (AVM) of the cervical and thoracic segments Right vertebral arteriography, anteroposterior (A) and lateral (B) views, demonstrates the superior aspect of a large intramedullary AVM that extends from C4 to T2. The nidus of the AVM fills the spinal canal from front to back and from side to side.
  40. 40. 06-Jan-16 40 On sagittal T1-weighted magnetic resonance imaging , the signal void from the AVM clearly involves not only the cross-sectional area of the spinal cord but also the anterior and posterior elements of the spine and paraspinous soft tissue
  41. 41. glomus type 06-Jan-16 41 Selective spinal cord arteriogram demonstrating a glomus-type intramedullary arteriovenous malformation supplied by the anterior spinal artery via the artery of Adamkiewicz
  42. 42. Feature SDAVF SCAVM Age >4th decade 2nd-3rd decade Symptom onset Slow progressive Acute Male predominance Yes (marked) Minimal Hemorrhage No Yes (frequent) Bruit No 5-10% Origin Acquired Congenital Site of nidus Dura, root sleeve Spinal cord Medullary arterial supply involved 10-15% 100% 06-Jan-1642
  43. 43. Perimedullary Fistula 06-Jan-1643
  44. 44. Perimedullary arteriovenous fistulas  Consist of direct AVF located on the cord and fed directly by arteries supplying the cord, most frequently the ASA  8-19 % of spinal AVM.  Single hole between one or more radiculomedullary arteries & perimedullary veins on the surface of cord .  Features that differentiate SCAVFs from both SDAVFs and SCAVMs  Intradural location of shunt,  constant involvement of arteries supplying the spinal cord, and  lack of intervening nidus 44 06-Jan-16 AV fistula
  45. 45. Etiology And Clinical Presentation  Believed to be congenital lesions, usually present in patients in their second through fourth decade  Most common neurologic presentation is one of progressive asymmetrical radiculomedullary signs involving lower extremities, reflecting the most common location of SCAVFs in the lower thoracic or lumbar region  Hemorrhage is also common and has been noted in nearly one third of patients at presentation  Three subtypes have been identified based on the size and number of vessels involved 06-Jan-16 45
  46. 46. Perimedullary AVF  A – Simple perimedullary fistula fed by single arterial branch. (Venous drainage minimally dilated)  B – Intermediate sized fistula with multiple dilated arterial feeders. (ASA & PSA are mildly dilated and draining vein markedly dilated)  C – Large perimedullary fistula with multiple giant arterial feeders.(Main supply is ASA and draining proximal venous segment is ectatic) 06-Jan-16 46
  47. 47. SYMPTOMS 06-Jan-16 47 Young adults , 2 – 4 Decade No sex predilection . Most common presentation : • Progressive asymmetrical radiculomedullary signs, involving lower extremities . • Progressive paraplegia without remission. • Impaired venous return & long intradural course of the venous drainage may be responsible for ascending myelopathy & spinal cord ischaemia . • Spinal SAH  In 1/3 patients .
  48. 48. IMAGING  Flow voids - enlarged feeding and draining vessels of SCAVF.  Intrinsic cord signal abnormality and evidence of hemorrhage may also be present.  Small size of some lesions and lack of nidus may make differentiation from SDAVF difficult.  Abnormal enhancement of the cord may be present. 06-Jan-16 48
  49. 49. PERIMEDULLARY AVF 3D PC MRAT1WI 06-Jan-1649
  50. 50. MRI SCAVM PMF SDAVF Flow voids + + + Parenchymal signal changes + + + Aneurysm + + - Hemorrhage + + - Nidus in the cord - - 06-Jan-1650
  51. 51. Radiological differences between dural AVM and Intradural Avm Dural AVM Intradural AVM Site of nidus Lateral canal 100% Within cord 80% Level of spine Lower half diffuse Rapid flow 0 80% Assoc aneurysm 0 44% Supply by medullary artery 15% 100% Route of drainage Rostral 100% Caudal 4% Rostral 81% Caudal 72% 06-Jan-1651
  52. 52. Cavernous Malformation  Cavernous malformations (CMs) are slow flow vascular malformations without AV shunting  3% to 5% of CMs involve the spine  Site- Most often intramedullary and occur proportionally throughout the cord  CMs of the spine have been noted to preferentially affect females  It can arise denovo, post radiotherapy and post traumatic. 06-Jan-16 52
  53. 53. Clinical presentation  Symptoms may begin at any age, patients most often present in the fourth decade  Acute presentation is probably secondary to hemorrhage either within vascular spaces of malformation or into surrounding parenchyma (hematomyelia)  Progressive myelopathy may result from growth or enlargement of the lesions by several mechanisms including vessel dilation, repeated hemorrhage, or capillary proliferation 06-Jan-16 53
  54. 54. IMAGING  Varies in size from mm to cms.  Well demarcated with low grade hemorrhage of varying ages  Surrounded by hemosiderin stained gliotic neural tissue.  Histology show single cell layer to hyalinized, thickened walls containing densely packed collagen but no elastic or smooth muscle fibres. 06-Jan-16 54
  55. 55. Cavernous Malformation- treatment 06-Jan-16 55  They are not subjects for endovascular treatment, and surgical resection is advocated for symptomatic lesions.  It is generally reserved for symptomatic lesions
  56. 56. AVM/AVF-Treatment Treatment planning for spinal vascular arteriovenous lesions is based on The hemodynamics of the lesion, Location in the axial and longitudinal plane, and The angioarchitecture. 06-Jan-16 56
  57. 57. EMBOLIC AGENTS Particulate materials  Poly vinyl alcohol(150-250micro) :Temporary & Reduces arterial steal safely.  Gelfoam  Sponge microparticulate Balloon occlusion Liquid agents  N-butyl cyanoacrylate (NBCA) : If AVM is supplied by only PSA  ethylene vinyl alcohol copolymer)  If AVM is supplied by ASA , embolization only if :  Normal anterior RMA supplying above & below the AVM.  Superselective catheterization , close to nidus. 06-Jan-16 57
  58. 58. Treatment - Dural AVF  Goal of treatment of spinal dural AVF is permanent elimination of of venous congestion of the spinal cord  Simple interruption of the AvF produces permanent resolution of venous congestion and improvement of myelopathy.  Medullary vein(arterialised) is coagulated  Neurological outcome is closely related to preop function. 06-Jan-16 58
  59. 59.  Endovascular occlusion of SDAVF is possible in more than 80% of cases and can be accomplished at the same time as the diagnostic angiogram using permanent liquid embolic agents such as NBCA(N-butyl cyanoacrylate) or ONYX.  Perimedullary venous thrombosis.  Clinical symptoms may worsen.  Post procedure anticoagulation for 3 months. Treatment - Dural AVF 06-Jan-16 59
  60. 60. TREATMENT : AVMs 06-Jan-16 60  Should be pursued aggressively because of the poor outcomes in untreated patients. AIM : To suppress the risk of hemorrhage & arrest progression of neurological defecit .  Maximum suppression of arterial steal may reverse a progressive neurological defecit.
  61. 61. EMBOLIZATION • Method of choice . • Risk of embolization is 3 to 5 times lower than surgery . • Angiographic criteria for endovascular approach is  Enlarged prominent ASA  Multiple commissural branches participating in AVM .  Normal ASA above or below the AVM . 06-Jan-16 61
  62. 62. TREATMENT : Perimedullary AVF 06-Jan-16 62 Type I: Embolisation is not indicated if the fistula is surgically accessible since surgery is the safer and more reliable treatment. • Catheterisation in the anterior spinal artery can be difficult and is always hazardous. • Fistulas situated on the ventral cord surface are candidates for embolisation which has been performed with particles (as a presurgical manoeuvre) or NBCA Type II: If the fistula is situated on the dorsal surface of the cord, surgical ligation and embolisation are of equal value and efficacy. • Ventral lesions are difficult cult to approach surgically but difficult cult to completely exclude by embolisation, if there are multiple feeders Type III: The high-flow and dilated vessels in this type makes surgery difficult, and embolisation with coils or liquids is usually performed as curative or presurgery procedures.
  63. 63. TREATMENT : Perimedullary AVF 06-Jan-16 63  SURGERY : 1. Smaller lesion , 2. AVF I & II , located posterior to the spinal cord 3. Endovascular treatment failed in AVF III .
  64. 64. Intradural arteriovenous fistula at surgery (A) Before, (B) After obliteration 06-Jan-16 64
  65. 65. Summary of outcomes of treatments for spinal vascular malformations 06-Jan-16 Intramedullary AVM Surgery Curative resection if possible Embolisation (curative or palliative) Particles: high recurrence NBCA: better cure rates Onyx: no data Perimedullary AVF Type I. Surgery (or embolisation) Surgery first-line treatment if AVF accessible NBCA embolisation, but particles may be safer Perimedullary AVF Type II EVT (or surgery) NBCA, particles or surgery Perimedullary AVF Type III EVT (surgery if incomplete) Coils, (balloons), NBCA or Onyx DAVF EVT (surgery if recurrent) NBCA or Onyx 65
  66. 66. Indications for occluding only the feeding vessels Dural AVM Intramedullary diffuse AVM Combined AVM Conus medullaris AVM 06-Jan-16 66
  67. 67. Complications Complications that result from open surgical ligation or resection  Infection of meninges (meningitis)  Cerebrospinal fluid leak  Wound dehiscence Complications that result from the endovascular technique  Femoral hematoma  Pseudoaneurysms and thrombosis  Arterial dissection 06-Jan-16 67
  68. 68. Stereotactic radiosurgery Single high dose SRS 20 to 30% rate of occlusion. Hypofractionated irradiation Internal fiducial markers and image‐guided radiation allow stereotactic irradiation for spinal disease with real‐time verification and an accuracy of ±1 mm for every 0.03 seconds 06-Jan-16 68
  69. 69. Type Typical location Vascular supply Presentation & course Clinical associations Treatment DAVF Lumbar, thoracic Dural arteries Chronic myelopathy None 1.Embolizati or 2.Surgery AVM Cervical, thoracic, Lumbar Spinal arteries (ASA, PSA) Acute; hemorrhage common Vascular syndromes; paraspinal involvement rarely 1.Embolizati or 2.Surgery PAVF Lumbar, thoracic Spinal arteries (ASA > PSA) Acute or chronic; may hemorrhage None 1.Embolizati or 2.Surgery CM Cervical, thoracic, Lumbar Minimal Acute or chronic; may hemorrhage Intracranial or familial CM Surgery 06-Jan-1669
  70. 70. Grade Gait 0 Normal 1 Leg weakness, abnormal gait or stance, but no restriction of activity 2 Restricted activity 3 Requiring 1 stick for walking 4 Requiring 2 sticks, crutches, or walker 5 Confined to wheelchair Grade Micturi tion 0 Normal 1 Hesitancy, frequency, urgency 2 Occasional urinary incontinence or retention 3 Total incontinence or persistent retention Modified Aminoff-Logue grading scale 06-Jan-1670
  71. 71. THANK YOU 06-Jan-1671
  • saurabhvarshney528

    Aug. 17, 2021
  • preslavpetkov31

    Aug. 7, 2021
  • drhardikpatel

    Jul. 13, 2021
  • abhijitdas291

    Jul. 5, 2021
  • ParthLalcheta1

    Jun. 22, 2021
  • DallasSheinberg

    May. 26, 2021
  • NassimArikirin

    May. 16, 2021
  • sombuddhadey3

    Apr. 20, 2021
  • RahulRoy404

    Mar. 25, 2021
  • nanearmworasin

    Feb. 7, 2021
  • AkhileshGowda3

    Jan. 5, 2021
  • SatabdiKalita1

    Nov. 14, 2020
  • MahendraPatel139

    Aug. 30, 2020
  • AvijitRoy55

    Jul. 30, 2020
  • AkhileshAgrawal4

    Jul. 23, 2020
  • rameshmutiki

    Jul. 16, 2020
  • venkideshKrishnamoor1

    Jun. 29, 2020
  • asimrimawi

    Apr. 10, 2020
  • VarikotiTriveni

    Feb. 23, 2020
  • GoktugULKU

    Jan. 24, 2020

Spinal avm

Views

Total views

6,600

On Slideshare

0

From embeds

0

Number of embeds

9

Actions

Downloads

992

Shares

0

Comments

0

Likes

49

×