Case Diagnosis: Non-traumatic Spinal Cord Injury Secondary to an Arteriovenous Malformation (AVM)
A 26-year-old transgender male presented with bilateral lower extremity weakness and hypoesthesia. MRI confirmed spinal cord stenosis and cord compression at T3-T6 secondary to a T4 AVM (Schobinger stage III). The patient previously received weekly testosterone injections (200mg) to induce gender affirmation, and likely contributed to the AVM development. He underwent successful vascular embolization, epidural hematoma evacuation, and T3-T6 laminectomy and fusion. His inpatient rehabilitation course was complicated by regression in strength and sensation throughout the lower extremities. A CT myelogram demonstrated severe narrowing at the T4 level secondary to hematoma recurrence. Patient underwent urgent T3-T6 decompression and hematoma evacuation. He resumed inpatient rehabilitation with improved lower extremity strength and sensation. In addition to common spinal cord injury impairments (pain, spasticity, neurogenic bowel and bladder), special attention was devoted to the patient’s gender identity and the discontinuation of his hormone treatments. A multidisciplinary approach involving psychiatry and psychology was utilized.
Over one year, the incidence of spinal AVMs in the USA is near 300. It has been reported that both males and females experience a two-fold risk of AVMs during adolescence, correlating with increased levels of sex hormones in circulation. While our patient was not an adolescent, he had been receiving regular exogenous hormone therapies. Additionally, Schobinger Stage III AVMs exhibit increased expression of endothelial progenitor cells and growth factors that promote vasculogenesis. This corresponds with increased rate of recurrence and hemorrhage.
AVMs are more susceptible to hemorrhage with progression of neovascularization, which has been associated with increased circulating testosterone and estrogen levels. Patients that are receiving exogenous sex hormone supplementation, especially at levels to induce gender affirmation, should be counseled on the potential development and advancement of AVMs as well as the risk of hemorrhage.
George Malik– Resident Physician, Shirley Ryan Ability Lab- Northwestern University
Emily Marquez– Resident Physician, Shirley Ryan AbilityLab
Eleasa Hulon– Resident Physician, Shirley Ryan Ability Lab/McGaw Medical Center of Northwestern University
Lynn Vidakovic– Attending Physician, Shirley Ryan Ability Lab