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Tanaka T, Yamane F, Sashida R, Hirokawa Y, Wakamiya T, Michiwaki Y, Shimoji K, Suehiro E, Onoda K, Matsuno A, Morimoto T. Delayed Diagnosis of Spinal Dural Arteriovenous Fistula: A Case Report and Scoping Review. J Clin Med 2024; 13:711. [PMID: 38337405 PMCID: PMC10856045 DOI: 10.3390/jcm13030711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Spinal dural arteriovenous fistula (SDAVF) is among the most common arterial shunt diseases typically found in middle aged or older men. Herein, we aimed to clarify the reasons for misdiagnoses and delayed diagnoses of SDAVF, determine how these affect prognoses, and establish how they can be prevented. We conducted a PubMed/MEDLINE literature search using "spinal dural arteriovenous fistula", "delayed diagnosis", "late diagnosis", and "misdiagnosis" terms. We identified 18 articles, including 965 SDAVF cases. Patients were predominantly males (71.8-100.0%) (mean age: 53.5-71.0 years). Misdiagnoses rates varied (17.5-100.0%) and encompassed many conditions. The mean time between early manifestations and confirmed diagnosis was approximately 10-15 months and from the first radiologic image revealing dural arteriovenous fistula (DAVF) features to diagnosis was 9.2-20.7 months. Posttreatment outcomes showed a significant improvement in motor functions, gait, and micturition, particularly in patients exhibiting preoperative symptoms over a short period. SDAVF is frequently misdiagnosed or subject to delayed diagnosis, causing poor clinical outcomes. SDAVF symptoms including progressive lower-limb weakness, paresthesia, and vesicorectal dysfunction are indications for spinal magnetic resonance imaging with subsequent spinal angiography, wherein DAVF is evidenced by extensive T2 hyperintensity and flow-void abnormalities. We reported a representative case with delayed diagnosis.
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Affiliation(s)
- Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Fumitaka Yamane
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Ryohei Sashida
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Yu Hirokawa
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Tomihiro Wakamiya
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Yuhei Michiwaki
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Kazuaki Shimoji
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Eiichi Suehiro
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Keisuke Onoda
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Akira Matsuno
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, 852 Hatakeda, Narita 2868520, Japan
| | - Tadatsugu Morimoto
- Department of Orthopedic Surgery, Faculty of Medicine, Saga University, Saga 849-8501, Japan
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Devalckeneer A, Bourgeois P, Caudron Y, Estrade L, Obled L, Leclerc X, Assaker R, Lejeune JP, Aboukais R. Surgical evolution in spinal dural arteriovenous fistula treatment-a 7 years monocentric experience. Neurosurg Rev 2023; 46:225. [PMID: 37670160 DOI: 10.1007/s10143-023-02131-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/10/2023] [Accepted: 08/28/2023] [Indexed: 09/07/2023]
Abstract
Accounting for 70% of all spinal vascular malformations, spinal dural arteriovenous fistulas (SDAVF) are the most common type of malformation. Interruption of the fistulous arterialized vein point is the goal of surgical treatment. The aim of the study was to compare open surgery (laminectomy) versus minimal invasive surgery (MIS) in SDAVF treatment. Between March 2013 and March 2020, we retrospectively collected 21 consecutive adult patients with SDAVF. Since March 2017, MIS has been routinely used for surgical treatment. Pre- and post-operative clinical evaluations used Aminoff-Logue score (ALS). Complication rate was noted. Post-operative occlusion of the malformation was confirmed by digital subtraction angiography (DSA) in all patients. MIS was compared to open surgery in terms of efficacy and complications with statistical evaluation. Standard laminectomy was performed in 12 patients and MIS technique in 9 patients. No difference was noted on pre-operative parameters. ALS and MRI signs of myelopathy were improved in all cases except for 1 patient in each group. All SDAVFs were excluded based on post-operative DSA. Significant differences were noted between the 2 groups in terms of perioperative blood loss (p<0.001), post-operative pain visual analog scale values (p<0.001), and first time out of bed (p<0.001). Wrong level surgery occurred in one patient in each group; patients were re-operated using the same technique. No infection or cerebrospinal fluid (CSF) leak was noted. In our experience, MIS is a safe alternative to open laminectomy for SDAVF treatment. MIS contributes to patient comfort and minimizes blood loss without increasing complication rate.
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Affiliation(s)
- Antoine Devalckeneer
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France.
- INSERM, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France.
| | - Philippe Bourgeois
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France
| | - Yohan Caudron
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France
| | - Laurent Estrade
- Department of Radiology, Lille University Hospital, Lille, France
| | - Louis Obled
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France
| | - Xavier Leclerc
- Department of Radiology, Lille University Hospital, Lille, France
| | - Richard Assaker
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France
| | - Jean-Paul Lejeune
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France
- INSERM, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
| | - Rabih Aboukais
- Department of Neurosurgery, Lille University Hospital, Rue E. Laine, 59037, Lille Cedex, France
- INSERM, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, F-59000, Lille, France
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Yunga Tigre J, Costello MC, Maddy K, Errante EL, Berger CC, Burks SS. Surgical Management of a Spinal Dural Arteriovenous Fistula. Cureus 2023; 15:e36533. [PMID: 37090331 PMCID: PMC10121182 DOI: 10.7759/cureus.36533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Spinal dural arteriovenous fistulas (SDAVFs) may have subtle clinical presentations and are often misdiagnosed. Clinical status gradually deteriorates following symptom onset making prompt identification and management essential. Here we present a case of a 67-year-old patient with rapidly progressing motor and sensory deficits to eventual right hemiplegia. Following imaging and surgical intervention, a thoracic SDAVF was identified and resected. This case report highlights a unique SDAVF with a stroke-like presentation. For patients with such presentation, without a clear source of intracranial pathology, spinal causes such as SDAVF could be considered.
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Affiliation(s)
- Joseph Yunga Tigre
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Meredith C Costello
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Krisna Maddy
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Emily L Errante
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, USA
| | - Connor C Berger
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
| | - Stephen S Burks
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, USA
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Younger DS. Spinal cord motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 196:3-42. [PMID: 37620076 DOI: 10.1016/b978-0-323-98817-9.00007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Spinal cord diseases are frequently devastating due to the precipitous and often permanently debilitating nature of the deficits. Spastic or flaccid paraparesis accompanied by dermatomal and myotomal signatures complementary to the incurred deficits facilitates localization of the insult within the cord. However, laboratory studies often employing disease-specific serology, neuroradiology, neurophysiology, and cerebrospinal fluid analysis aid in the etiologic diagnosis. While many spinal cord diseases are reversible and treatable, especially when recognized early, more than ever, neuroscientists are being called to investigate endogenous mechanisms of neural plasticity. This chapter is a review of the embryology, neuroanatomy, clinical localization, evaluation, and management of adult and childhood spinal cord motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Kienzler JC, Schoepf S, Marbacher S, Diepers M, Remonda L, Fandino J. Intraoperative Spinal Angiography during Microsurgical Occlusion of Spinal Dural Arteriovenous Fistula within the Hybrid Operation Room. J Neurol Surg A Cent Eur Neurosurg 2021; 83:486-493. [PMID: 34929752 DOI: 10.1055/s-0041-1736634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Spinal dural arteriovenous fistula (SDAVF) is a rare cause of progressive myelopathy in predominantly middle-aged men. Treatment modalities include surgical obliteration and endovascular embolization. In surgically treated cases, failure of obliteration is reported in up to 5%. The aim of this technical note is to present a safe procedure with complete SDAVF occlusion, verified by intraoperative digital subtraction angiography (DSA). METHODS We describe four patients with progressive leg weakness who underwent surgical obliteration of SDAVF with spinal intraoperative DSA in the prone position after cannulation of the popliteal artery. All surgeries took place in our hybrid operating room (OR) and were accompanied by electrophysiologic monitoring. Surgeries and cannulation of the popliteal artery were performed in the prone position. Ultrasound was used to guide the popliteal artery puncture. A 5-Fr sheath was inserted and the fistula was displayed using a 5-Fr spinal catheter. Spinal intraoperative DSA was performed prior to and after temporary clipping of the fistula point as well after the final SDAVF occlusion. RESULTS The main feeder of the SDAVF fistula in the first patient arose from the right T11 segmental artery, which also supplied the artery of Adamkiewicz. The second patient initially underwent endovascular treatment and deteriorated 5 months later due to recanalization of the SDAVF via a small branch of the T12 segmental artery. The third and fourth cases were primarily scheduled for surgical occlusion. Access through the popliteal artery for spinal intraoperative DSA proved to be beneficial and safe in the hybrid OR setting, allowing the sheath to be left in place during the procedure. During exposure and after temporary and permanent occlusion of the fistulous point, intraoperative indocyanine green (ICG) video angiography was also performed. In one case, the addition of intraoperative DSA showed failure of fistula occlusion, which was not visible with ICG angiography, leading to repositioning of the clip. Complete fistula occlusion was documented in all cases. CONCLUSION Spinal intraoperative DSA in the prone position is a feasible and safe intervention for rapid localization and confirmation of surgical SDAVF occlusion.
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Affiliation(s)
| | - Salome Schoepf
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Michael Diepers
- Division of Neuroradiology, Kantonsspital Aarau (KSA) - Kantonsspital Aarau (KSA), Tellstrasse, Aarau, Switzerland
| | - Luca Remonda
- Division of Neuroradiology, Kantonsspital Aarau (KSA) - Kantonsspital Aarau (KSA), Tellstrasse, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland
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Treatment strategy to maximize the treatment outcome of spinal dural arteriovenous fistula after initial endovascular embolization attempt at diagnostic angiography. Sci Rep 2021; 11:10004. [PMID: 33976351 PMCID: PMC8113326 DOI: 10.1038/s41598-021-89407-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/19/2021] [Indexed: 12/04/2022] Open
Abstract
Initial attempt of endovascular treatment (EVT) for spinal dural arteriovenous fistula (SDAVF) is preferred because of concurrent diagnosis and treatment. However, outcomes following further treatment with initial EVT are not well studied. We retrospectively reviewed 71 patients with SDAVF to evaluate treatment outcomes of SDAVF after an initial EVT attempt. Pretreatment and posttreatment functional states were assessed by the Aminoff-Logue scale (ALS). In the case of incomplete occlusion or recurrence, overall outcomes after further treatments were compared. Of the 71 patients, 56 underwent initial EVT. Complete occlusion was achieved by initial EVT in 37 of 56 patients (66.1%). Multiple feeders were more frequently observed in patients with incomplete occlusion than complete occlusion after initial EVT (73.7% vs. 27%, P < 0.001). Among 19 patients with incomplete occlusion upon initial EVT, 14 underwent additional surgery, 13 of whom (92.9%) obtained improved or stationary functional outcomes. Functional improvement was not observed in patients who had repeated EVT or follow-up without further treatment. Recurrence was observed in 8 of 37 patients with complete occlusion upon initial EVT. Additional surgery achieved improved functional outcomes in cases of incomplete occlusion of SDAVF after the initial EVT attempt or recurrence rather than repeated EVT or follow-up.
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Spinal vascular malformations: Angiographic evaluation and endovascular management. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:267-304. [PMID: 33272400 DOI: 10.1016/b978-0-444-64034-5.00013-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Spinal vascular malformations (SVM) are classified based on their location (intramedullary, perimedullary, radicular, extradural) and flow pattern (high-flow, low-flow, no arteriovenous shunt). High-flow SVMs are generally congenital lesions diagnosed in children and young patients without gender predominance. They present with hemodynamic disturbances, mass effect, or hemorrhages, but may also be discovered incidentally. Low-flow SVMs tend to be acquired lesions presenting in older men with progressive myelopathy caused by spinal venous hypertension. They are rarely associated with vascular syndromes but may accompany prothrombotic conditions. The sensitivity and specificity of conventional MRI are excellent for high-flow SVMs but poor for low-flow lesions, which are frequently diagnosed with extensive delays reducing the potential for favorable outcomes. The sensitivity of advanced MRI techniques remains unclear, notably for the detection of low-flow shunts without flow voids on conventional MRI. Catheter angiography remains the gold standard modality for the evaluation of the spinal vasculature and its disorders. SVMs can be treated by surgical or endovascular means. Initially plagued by high recurrence rates due to inadequate embolization material, endovascular techniques represent nowadays a valid alternative to surgery, thanks notably to the introduction of liquid embolic agents.
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Functional Outcome in Patients with Dural Arteriovenous Fistulae after Surgical Treatment. SURGERIES 2020. [DOI: 10.3390/surgeries1020007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Spinal dural arterio-venous fistulas (SDAVF) are rare vascular pathologies. Degree of symptom improvement after surgery remains unclear. We evaluated surgically treated SDAVF patients for functional outcome and symptom improvement. Retrospective inclusion of consecutive patients treated surgically in our department between 2007–2019. We measured functional outcome using the McCormick Scale and modified Japanese Orthopaedic Association (mJOA) score. We included 27 patients with a median follow-up of 8.8 months (IQR 27.8). Mean age was 61.8 years (SD 8.4), 40.7% were female. Most frequent location was the thoracic spine in 15 (55.6%) followed by lumbar in 8 (29.6%), cervical in 3 (11.1%) and sacral spine in one patient (3.7%). Most common presenting symptom was progressive myelopathy (24/27 patients, 88.9%). In all patients the SDAVF was completely resected; however, four patients (14.8%) required a second surgery. Six patients (22.2%) deteriorated immediately after surgery with five recovering to baseline upon discharge. On discharge, presenting symptoms had improved in 17 patients (63%); 8/25 patients (32%) had a McCormick score of 1. Twenty (74.1%) continued to improve on follow-up. In total 23/27 patients (85.2%) improved. In the univariable analysis mJOA score on admission was associated with mJOA score on follow-up (coefficient 0.6, 95%CI 0.4–0.81, p < 0.001), whereas age was inversely associated (coefficient −0.1, 95%CI −0.19–0.01, p = 0.08). Untreated SDAVF leads to progressive myelopathy which may result in considerable disability. Surgical disconnection and resection provides a safe treatment option with low perioperative morbidity and excellent chances for symptom improvement or progression prevention.
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Petrin Z, Marino RJ, Oleson CV, Simon JI, McCormick ZL. Paralysis After Lumbar Interlaminar Epidural Steroid Injection in the Absence of Hematoma: A Case of Congestive Myelopathy Due to Spinal Dural Arteriovenous Fistula and a Review of the Literature. Am J Phys Med Rehabil 2020; 99:e107-e110. [PMID: 31592878 DOI: 10.1097/phm.0000000000001325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Paraplegia after interlaminar epidural steroid injection is a rare event and has typically been described after epidural hematoma or direct spinal cord injury. We present a case of an 87-yr-old man who experienced transient lower limb weakness after a lumbar interlaminar epidural steroid injection due to an alternative cause, congestive myelopathy related to an underlying vascular malformation, namely, a spinal dural arteriovenous fistula. This is a poorly recognized and potentially treatable cause of progressive myelopathy. We present this case and review the literature on paraplegia after epidural steroid injection due to spinal dural arteriovenous fistula. Notably, this case of paralysis occurred in association with the lowest volume of epidural injectate reported in the literature to date (4 ml); importantly, this volume is consistent with the current clinical practice guideline standards for the safe performance of interlaminar epidural steroid injections. Physicians should be aware of this potential complication of epidural steroid injection and remain vigilant for the possibility after a procedure, even when performed according to current practice standards.
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Affiliation(s)
- Ziva Petrin
- From the Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah (ZP, ZLM); Department of Rehabilitation Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia Pennsylvania (RJM); Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, Ohio (CVO); and Division of Physical Medicine and Rehabilitation, The Rothman Institute of Thomas Jefferson University, Philadelphia, Pennsylvania (JIS)
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Goyal A, Cesare J, Lu VM, Alvi MA, Kerezoudis P, Brinjikji W, Nasr D, Lanzino G, Bydon M. Outcomes following surgical versus endovascular treatment of spinal dural arteriovenous fistula: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2019; 90:1139-1146. [PMID: 31142659 DOI: 10.1136/jnnp-2019-320648] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/13/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
Although surgical resection is associated with a complete cure in most cases of spinal dural arteriovenous fistulas (SDAVF), there has been an increasing trend towards embolisation. We performed a systematic review and meta-analysis comparing surgical resection with endovascular treatment in terms of success of treatment, rate of recurrence and complications. A literature search was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Strength of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation Working Group system. Surgical outcomes such as initial treatment failure, late recurrence, neurological improvement and complications were compared between the two approaches. We included 57 studies with 2029 patients, of which 32 studies with 1341 patients directly compared surgery (n=590) and embolisation (n=751). Surgery was found to be associated with significantly lower odds of initial treatment failure (OR: 0.15, 95% CI 0.09 to 0.24, I2 0%, p<0.001) and late recurrence (OR 0.18, 95% CI 0.09 to 0.39, I2 0%, p<0.001). The odds of neurological improvement following surgery were also significantly higher compared with embolisation alone (OR: 2.73, CI:1.67 to 4.48, I2 :49.5%, p<0.001). No difference in complication rates was observed between the two approaches (OR 1.78, 95% CI 0.97 to 3.26, I2 0%, p=0.063). Onyx was associated with significantly higher odds of initial failure/late recurrence as compared with n-butyl 2-cyanoacrylate (OR: 3.87, CI: 1.73 to 8.68, I2 :0%, p<0.001). Surgery may be associated with superior outcomes for SDAVFs in comparison to endovascular occlusion. Newer embolisation agents like Onyx have not conferred a significant improvement in occlusion rate.
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Affiliation(s)
- Anshit Goyal
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph Cesare
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor M Lu
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Deena Nasr
- Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohamad Bydon
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Yamahata H, Yamaguchi S, Osanai T, Takeda M, Mitsuhara T, Mori M, Tanaka S, Yonenaga M, Taguchi A, Watanabe Y, Abiko M, Seki T, Sasamori T, Arita K, Yoshimoto K. Cauda Equina Occupation Ratio as a New Imaging Parameter for the Evaluation of Spinal Dural Arteriovenous Fistulae. World Neurosurg 2019; 130:e1020-e1027. [PMID: 31306848 DOI: 10.1016/j.wneu.2019.07.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Because spinal dural arteriovenous fistulae (SDAVF) are rare and their clinical presentation is nonspecific, they are often overlooked during diagnostic evaluations. Typical magnetic resonance imaging (MRI) findings are intramedullary T2-weighted signal hyperintensity and perimedullary flow voids. There are few reports on the characteristic signs of the cauda equina. We assessed the significance of a new imaging parameter, the cauda equina occupation ratio (CEOR), for the evaluation of SDAVF. METHODS We retrospectively analyzed the clinical charts and radiological findings of 20 SDAVF patients treated at our institutions. We evaluated sagittal T2-weighted MRI scans and assessed the CEOR, the occupation ratio of the cauda equina compared to the sagittal diameter of the corresponding lumbar spinal canal. The controls were 21 age- and sex-matched subjects. RESULTS Of the 20 SDAVF, 10 were at the thoracic and 10 at the lumbar spine. There was no significant difference between the preoperative CEOR and the spinal level of the fistulae or the neurological signs. On preoperative MRI scans, the mean CEOR was 56.0 ± 7.8; postoperatively, it was 37.1 ± 7.4 (P = 0.000). The preoperative CEOR was significantly larger in SDAVF patients than in the controls (P = 0.000); postoperatively, it was smaller than in the controls (P = 0.14). CONCLUSIONS The preoperative CEOR was larger in patients with SDAVF than in the controls. It normalized after successful occlusion of the fistula. Our findings indicate that the CEOR is a useful parameter for the pre- and postoperative evaluation of SDAVF.
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Affiliation(s)
- Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | - Satoshi Yamaguchi
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaaki Takeda
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Takafumi Mitsuhara
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Masanao Mori
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Shunichi Tanaka
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masanori Yonenaga
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Akira Taguchi
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Yosuke Watanabe
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Masaru Abiko
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Toshitaka Seki
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toru Sasamori
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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12
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Iglesias Gordo J, Martínez García R. Spinal dural arteriovenous fistulas: the most frequent vascular malformations of the spinal cord. RADIOLOGIA 2017; 60:237-249. [PMID: 29110903 DOI: 10.1016/j.rx.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022]
Abstract
Spinal dural arteriovenous fistulas are produced by direct communication between the arterial and venous systems of the spinal cord, causing hypertension in the latter with spinal cord dysfunction. It is a rare pathology with unknown etiology and non-specific clinical symptoms that usually results in a delayed diagnosis. Often radiologists are the first to guide the disease towards an adequate diagnosis. Characteristic findings can be seen through MR or MR angiography, and may even locate the fistula in a high percentage of cases, although the pathology must be confirmed by spinal angiography. There are two treatment modalities: endovascular and surgical therapy. Endovascular treatment has improved in recent years with the advantages of a less invasive approach and is therefore usually chosen as primary therapy. In this article we review the main clinical manifestations, imaging findings and treatment of this pathology.
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Affiliation(s)
- J Iglesias Gordo
- Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - R Martínez García
- Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, España
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Degree and Duration of Functional Improvement on Long-Term Follow-Up of Spinal Dural Arteriovenous Fistulae Occluded by Endovascular and Surgical Treatment. World Neurosurg 2017; 107:488-494. [DOI: 10.1016/j.wneu.2017.07.140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/22/2017] [Accepted: 07/24/2017] [Indexed: 11/23/2022]
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14
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Lagman C, Chung LK, Chitale RV, Yang I. Dural Arteriovenous Fistula and Foix-Alajouanine Syndrome: Assessment of Functional Scores with Review of Pathogenesis. World Neurosurg 2017; 106:206-210. [DOI: 10.1016/j.wneu.2017.06.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 12/16/2022]
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Neurologic Decline After Spinal Angiography for Dural Arteriovenous Fistula and Improvement with Emergent Surgical Ligation. World Neurosurg 2016; 92:587.e15-587.e18. [DOI: 10.1016/j.wneu.2016.04.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 04/25/2016] [Accepted: 04/27/2016] [Indexed: 01/31/2023]
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Bakker NA, Uyttenboogaart M, Luijckx GJ, Eshghi OS, Mazuri A, Metzemaekers JDM, Groen RJM, Van Dijk JMC. Recurrence Rates After Surgical or Endovascular Treatment of Spinal Dural Arteriovenous Fistulas: A Meta-analysis. Neurosurgery 2016; 77:137-44; discussion 144. [PMID: 25790071 DOI: 10.1227/neu.0000000000000727] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is an increasing tendency to treat spinal dural arteriovenous fistulas (SDAVFs) endovascularly despite the lack of clear evidence favoring embolization over surgery. OBJECTIVE To compare the initial failure and recurrence rates of primary treatment of SDAVFs by surgery and endovascular techniques. METHODS A meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standard was performed. All the English literature from 2004 onward was evaluated. From each article that compared the 2 treatment modalities, the odds ratio (OR) was calculated. Combined ORs were calculated with Review Manager 5.3 of The Cochrane Collaboration. RESULTS A total of 35 studies harboring 1112 patients were assessed. Initial definitive fistula occlusion was observed in 588 of 609 surgical patients (96.6%; 95% confidence interval [CI], 94.8-97.8) vs 363 of 503 endovascularly treated patients (72.2%; 95% CI, 68.1-75.9; P < .001). The combined OR from 18 studies that assessed both treatment modalities (730 patients) was 6.15 (95% CI, 3.45-11.0) in favor of surgical treatment. Late recurrence (13 studies, 480 patients) revealed an OR of 3.15 (95% CI, 1.66-5.96; P < .001) in favor of surgery. In a subgroup, recurrence was reported in 10 of 22 patients (45%) treated with Onyx vs 8 of 35 (23%) treated with n-butyle-2-cyanoacrylate (OR, 2.51; 95% CI, 0.75-8.37; P = .13). CONCLUSION Although hampered by inclusion of poor quality studies, this meta-analysis shows a definite advantage of primary surgical treatment of SDAVF over endovascular treatment in initial failure rate and late recurrences. The often-used argument that endovascular techniques have improved and therefore outweigh surgery is not supported by this meta-analysis.
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Affiliation(s)
- Nicolaas A Bakker
- From the Departments of *Neurosurgery, ‡Radiology, and §Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Saliou G, Krings T. Vascular diseases of the spine. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:707-16. [PMID: 27430437 DOI: 10.1016/b978-0-444-53486-6.00034-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Brinjikji W, Nasr DM, Morris JM, Rabinstein AA, Lanzino G. Clinical Outcomes of Patients with Delayed Diagnosis of Spinal Dural Arteriovenous Fistulas. AJNR Am J Neuroradiol 2015; 37:380-6. [PMID: 26338916 DOI: 10.3174/ajnr.a4504] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 06/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal dural arteriovenous fistulas are commonly missed on imaging or misdiagnosed as inflammatory or neoplastic processes. We reviewed a consecutive series of spinal dural arteriovenous fistulas referred to our institution that were missed or misdiagnosed on initial imaging and studied the clinical consequences of missing or misdiagnosing the lesion. MATERIALS AND METHODS We reviewed spinal dural arteriovenous fistulas diagnosed at our institution between January 1, 2000, and November 1, 2014. A lesion was defined as "misdiagnosed" if initial MR imaging or CT myelography demonstrated characteristic imaging features of spinal dural arteriovenous fistula but the patient was clinically or radiologically misdiagnosed. Outcomes included length of delay of diagnosis, increased disability (increase in mRS or Aminoff motor disability of ≥1 point) between initial imaging evaluation and diagnosis date, and posttreatment disability. RESULTS Fifty-three consecutive spinal dural arteriovenous fistulas that were initially misdiagnosed despite having characteristic imaging findings on MR imaging or CT myelography were included in our study. Eight patients (18.9%) underwent spinal angiography before referral, which was interpreted as having negative findings but was either incomplete (6 cases) or retrospectively demonstrated the spinal dural arteriovenous fistulas (2 cases). The median time of delayed diagnosis was 6 months (interquartile range, 2-14 months). Fifty-one patients (96.2%) had increased disability between the initial study, which demonstrated features of a spinal dural arteriovenous fistula, and diagnosis. Thirty-two patients (60.4%) developed a new requirement for a walker or wheelchair. Following treatment, 21 patients (41.2%) had an improvement of 1 point on the mRS or Aminoff motor disability scale. CONCLUSIONS Delayed diagnosis of spinal dural arteriovenous fistula with characteristic imaging features results in high rates of additional disability that are often irreversible despite surgical or endovascular treatment of the fistula.
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Affiliation(s)
- W Brinjikji
- From Departments of Radiology (W.B., J.M.M.)
| | | | - J M Morris
- From Departments of Radiology (W.B., J.M.M.)
| | | | - G Lanzino
- Neurosurgery (G.L.) Center for Science of Healthcare Delivery (G.L.), Mayo Clinic, Rochester, Minnesota
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Surgical Treatment of Spinal Dural Arteriovenous Fistula: Management and Long-Term Outcome in a Single-Center Series. World Neurosurg 2015; 83:1002-5. [DOI: 10.1016/j.wneu.2015.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/12/2015] [Accepted: 02/13/2015] [Indexed: 11/18/2022]
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Hamdan A, Padmanabhan R. Intramedullary hemorrhage from a thoracolumbar dural arteriovenous fistula. Spine J 2015; 15:e9-16. [PMID: 25463404 DOI: 10.1016/j.spinee.2014.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 09/19/2014] [Accepted: 10/07/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal dural arteriovenous fistulas (AVFs) are acquired lesions presenting typically with neurologic deficits secondary to chronic congestive myelopathy. The low-flow and low-volume nature of these lesions makes hemorrhage very unlikely, and intramedullary hemorrhage caused by thoracolumbar dural AVFs is exceedingly rare. PURPOSE The purpose of this study was to report a case of intramedullary hemorrhage caused by a thoracolumbar dural AVF. STUDY DESIGN/SETTING The study design included a case report and review of literature. METHODS A case of intramedullary hemorrhage from a thoracolumbar dural AVF was reported, and the literature regarding hemorrhagic presentations of dural AVF was reviewed. RESULTS A 66-year-old woman presented with a sudden onset of abdominal pain, paraplegia, sensory loss below the costal margins, and urinary retention. Magnetic resonance imaging scan showed intramedullary hemorrhage with abnormal flow voids raising suspicion of an intramedullary AV malformation. However, subsequent selective spinal angiography demonstrated a spinal dural AVF fed by the T7 intercostal artery and a varix within the draining vein. Complete obliteration of the dural AVF and the varix was achieved via embolization. As far as we are aware, there are only two other similar cases in the literature. Literature review revealed that presentation of thoracolumbar dural AVFs with hemorrhage is frequently associated with accelerated venous flow and the presence of a venous varix. CONCLUSIONS Although very unusual, a spinal dural AVF may present with intramedullary hemorrhage, and hemorrhage in such conditions may be associated with an accelerated venous flow and the presence of a venous varix.
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Affiliation(s)
- Alhafidz Hamdan
- Department of Neurosurgery, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough TS4 3BW, UK
| | - Rajeev Padmanabhan
- Department of Neuroradiology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough TS4 3BW, UK.
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Sudhir G, Acharya S, Kalra K, Chahal R. Arteriovenous malformation mimicking tuberculosis of spine with myelitis. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2015. [DOI: 10.1016/j.injms.2015.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Alhilali LM, Reynolds AR, Fakhran S. Value of prominent flow voids without cord edema in the detection of spinal arteriovenous fistulae. PLoS One 2014; 9:e99004. [PMID: 24905497 PMCID: PMC4048235 DOI: 10.1371/journal.pone.0099004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 05/09/2014] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To determine the prevalence of spinal dural arteriovenous fistulae (SDAVF) in patients presenting with prominent vascular flow voids on imaging without other imaging findings suggestive of SDAVF. METHODS We retrospectively identified patients from January 1, 2005 to March 1, 2012 who underwent spinal angiography for suspected SDAVF with prominent vascular flow voids on prior imaging. We excluded patients with other major spinal pathology or other imaging findings of SDAVF including cord hyperintensity, enhancement, or expansion. We calculated the proportion of patients with positive findings for SDAVF on angiography and evaluated the prevalence of SDAVF for this finding alone and in correlation with clinical findings. RESULTS 18 patients underwent spinal angiography for prominent flow voids on imaging without other spinal pathology or imaging findings of SDAVF. Three had a SDAVF detected on angiography. The prevalence of SDAVF in this population was low, only 17% (95% CI 6-39%). All of the patients with positive angiography findings had myelopathy, increasing the prevalence to 100% if the additional clinical finding of myelopathy was present. CONCLUSIONS Prominent flow voids without other imaging findings suggestive of SDAVF is poorly predictive of the presence of a SDAVF, unless myelopathy is present clinically.
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Affiliation(s)
- Lea M. Alhilali
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Arich R. Reynolds
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Saeed Fakhran
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
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Koerts G, Vanthuyne V, Delavallee M, Rooijakkers H, Raftopoulos C. Spinal dural arteriovenous fistula presenting with paraplegia following lumbar puncture. J Neurosurg Spine 2013; 19:57-60. [DOI: 10.3171/2013.3.spine12888] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal dural arteriovenous fistulas are rare lesions with an annual incidence of 1 per 100,000 population. In patients with this disease, an abnormal vascular dural shunt exists between a dural branch of a segmental artery and a subdural radicular vein that drains the perimedullary venous system, leading to venous hypertension and secondary congestive myelopathy. Generally, patients present with progressive paraparesis, urinary disturbances, and gait ataxia. In this report the authors describe a 61-year-old woman with a spinal dural arteriovenous fistula who developed an acute paraplegia after a nontraumatic lumbar puncture. The possible underlying mechanisms and treatment options are discussed.
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Wang G, Ma G, Ma J, Hao S, Li D, Han L, Wang T, Su W, Han B, Yen CP, Kwan AL. Surgical treatment of spinal vascular malformations performed using intraoperative indocyanine green videoangiography. J Clin Neurosci 2013; 20:831-6. [DOI: 10.1016/j.jocn.2012.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 05/28/2012] [Accepted: 06/01/2012] [Indexed: 11/25/2022]
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Marcus J, Schwarz J, Singh IP, Sigounas D, Knopman J, Gobin YP, Patsalides A. Spinal Dural Arteriovenous Fistulas: A Review. Curr Atheroscler Rep 2013; 15:335. [DOI: 10.1007/s11883-013-0335-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ofran Y, Yovchev I, Hiller N, Cohen J, Rubin SA, Schwartz I, Meiner Z. Correlation between time to diagnosis and rehabilitation outcomes in patients with spinal dural arteriovenous fistula. J Spinal Cord Med 2013; 36:200-6. [PMID: 23809589 PMCID: PMC3654445 DOI: 10.1179/2045772312y.0000000029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Spinal dural arteriovenous fistulas (SDAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy although they are under diagnosed. Surgical or embolization treatment of SDAVFs improved significantly in the last decade. However, a high percentage of patients are still left with severe disability. OBJECTIVE To describe the correlation between time to diagnosis and the rehabilitation outcomes of eight patients with SDAVFs. DESIGN Retrospective chart study of all SDAVF patients in 20 years. SETTING A tertiary university rehabilitation center. MAIN OUTCOME MEASURES The lower extremities motor score (LEMS), Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM) and Walking Scale for Spinal Cord Injury (WISC II). Overall prognosis was evaluated using the Aminoff-Logue scale (ALS). RESULTS There were seven men and one woman with mean age of 61.3 ± 15 (30-72) and mean time until the diagnosis of SDAVF of 265.5 ± 245 days (4-730). At the end of rehabilitation period, five of the eight patients remained wheelchair dependent. Strong correlation was found between LEMS, FIM, SCIM, and WISC II scores and the functional level according to the ALS scale. A significant correlation was found between time to diagnosis and the height of the SDAVF, the clinical and rehabilitation outcomes. Patients with high SDAVF which were diagnosed late had the poorest prognosis. CONCLUSIONS The potential for functional ambulation in patients with SDAVF is related to the time of intervention. This finding emphasizes the important of early diagnosis and early intervention in SDAVF.
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Affiliation(s)
| | | | | | | | | | | | - Zeev Meiner
- Correspondence to: Zeev Meiner, Department of Physical Medicine and Rehabilitation, Hadassah University Hospital, Jerusalem 91240, PO Box 24035, Israel.
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Gemmete JJ, Chaudhary N, Elias AE, Toma AK, Pandey AS, Parker RA, Davagnanam I, Maher CO, Brew S, Robertson F. Spinal dural arteriovenous fistulas: clinical experience with endovascular treatment as a primary therapy at 2 academic referral centers. AJNR Am J Neuroradiol 2013; 34:1974-9. [PMID: 23620076 DOI: 10.3174/ajnr.a3522] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Spinal dural arteriovenous fistulas are a rare entity that, if left untreated, can lead to considerable morbidity with progressive spinal cord symptoms. The aim of this study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas that were primarily treated with endovascular embolization. MATERIALS AND METHODS A retrospective review was performed of all patients from 1997-2010 who underwent treatment at 2 academic referral centers for a spinal dural arteriovenous fistula. Follow-up was performed by clinical examination, and functional status was measured by use of the Aminoff-Logue Disability Scale, McCormick classification grading, and mRS scores. The nonparametric Wilcoxon signed rank test was used to compare pretreatment and posttreatment Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and mRS scores. P values < .05 were considered significant. RESULTS A total of 38 patients were included. Five patients (2 endovascular, 3 surgical) were lost to follow-up and therefore were excluded from the analysis, 29 patients were initially treated from an endovascular approach (9 Onyx, 20 cyanoacrylate), and 4 patients were treated from a standard surgical approach. Five patients in the endovascular group subsequently underwent surgery for various reasons. The clinical improvements in the Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and the mRS scores were statistically significant (P < .05, Wilcoxon signed rank test). CONCLUSIONS We conclude that endovascular treatment of spinal dural arteriovenous fistulas can result in good clinical outcomes. Surgery remains the treatment of choice when safe embolization of the proximal radicular draining vein cannot be obtained or because the shunting artery of the spinal dural arteriovenous fistula also supplies the anterior spinal, posterior spinal, or a radiculomedullary artery.
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Inflammatory, vascular, and infectious myelopathies in children. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:999-1017. [PMID: 23622308 DOI: 10.1016/b978-0-444-52910-7.00020-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute nontraumatic myelopathies of childhood include inflammatory, infectious, and vascular etiologies. Inflammatory immune-mediated disorders of the spinal cord can be categorized as idiopathic isolated transverse myelitis, neuromyelitis optica, and multiple sclerosis. In recent years, human T-cell lymphotropic virus type 1, West Nile virus, enterovirus-71, and Lyme disease have been increasingly recognized as infectious etiologies of myelopathy, and poliomyelitis remains an important etiology in world regions where vaccination programs have not been universally available. Vascular etiologies include vasculopathies (systemic lupus erythematosus, small vessel primary angiitis of the central nervous system), arteriovenous malformations, and spinal cord infarction (fibrocartilaginous embolism, diffuse hypoxic ischemia-mediated infarction). Vascular myelopathies are less common than inflammatory and infectious myelopathies, but are more likely to lead to devastating clinical deficits. Current therapeutic strategies include acute anti-inflammatory treatment and rehabilitation. Stem cell transplantation, nerve graft implantation, and stimulation of endogenous repair mechanisms represent promising strategies for spinal cord repair.
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Abstract
Spinal dural arteriovenous fistulas are rare spinal vascular malformations which can cause progressive paraparesis and paraplegia if not treated. As symptoms are unspecific diagnosis is often delayed and clinical outcome is dependent on early therapy. While magnetic resonance imaging (MRI) is the first choice imaging procedure, selective spinal digital subtraction angiography is necessary to analyze the angioarchitecture and to plan the treatment. This article provides an overview on the epidemiology, etiology, clinical aspects and imaging features as well as therapeutic aspects of spinal dural arteriovenous fistulas. Knowledge of spinal vascular anatomy is the basis for understanding spinal dural arteriovenous fistulas.
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Miller TR, Eskey CJ, Mamourian AC. Absence of abnormal vessels in the subarachnoid space on conventional magnetic resonance imaging in patients with spinal dural arteriovenous fistulas. Neurosurg Focus 2012; 32:E15. [DOI: 10.3171/2012.2.focus1214] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Spinal dural arteriovenous fistula (DAVF) is an uncommon condition that can be difficult to diagnose. This often results in misdiagnosis and treatment delay. Although conventional MRI plays an important role in the initial screening for the disease, the typical MRI findings may be absent. In this article, the authors present a series of 4 cases involving patients with angiographically proven spinal DAVFs who demonstrated cord T2 prolongation on conventional MRI but without abnormal subarachnoid flow voids or enhancement. These cases suggest that spinal DAVF cannot be excluded in symptomatic patients with cord edema based on conventional MRI findings alone. Dynamic Gd-enhanced MR angiography (MRA) was successful in demonstrating abnormal spinal vasculature in all 4 cases. This limited experience provides support for the role of spinal MRA in patients with abnormal cord signal and symptoms suggestive of DAVF even when typical MRI findings of a DAVF are absent.
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Affiliation(s)
- Timothy R. Miller
- 1Division of Neuroradiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Clifford J. Eskey
- 2Neuroradiology, Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexander C. Mamourian
- 1Division of Neuroradiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
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Linfante I, Tari Capone F, Dabus G, Gonzalez-Arias S, Lau PE, Samaniego EA. Spinal arteriovenous malformation associated with spinal metameric syndrome: a treatable cause of long-term paraplegia? J Neurosurg Spine 2012; 16:408-13. [PMID: 22225485 DOI: 10.3171/2011.12.spine11636] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cutaneomeningospinal angiomatosis, or Cobb syndrome, is a rare metameric developmental disorder presenting as an extradural-intradural vascular malformation that involves bone, muscle, skin, spinal cord, and nerve roots. A 14-year-old girl with a red nevus involving the T6-9 dermatomes on the left side of her back presented with a 5-year history of bowel and bladder incontinence, paraplegia, and lower-extremity sensory loss. Magnetic resonance imaging demonstrated a hemangioma in the T-8 and T-9 vertebral bodies and a spinal cord AVM nidus extending from T-6 to T-9. The AVM was successfully embolized and the patient regained lower-extremity strength, ambulation, and normal sphincter functions after 5 years of having been wheelchair bound. The authors report the restoration of ambulation after endovascular embolization of a large spinal AVM in a patient with long-standing paraplegia due to Cobb syndrome.
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Affiliation(s)
- Italo Linfante
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA.
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Ruiz-Juretschke F, Perez-Calvo JM, Castro E, García-Leal R, Mateo-Sierra O, Fortea F, Iza B, Garbizu JM, Villoria F. A single-center, long-term study of spinal dural arteriovenous fistulas with multidisciplinary treatment. J Clin Neurosci 2011; 18:1662-6. [DOI: 10.1016/j.jocn.2011.03.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 03/07/2011] [Accepted: 03/09/2011] [Indexed: 11/24/2022]
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34
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Vascular Malformations of the Spine and Spinal Cord*. Clin Neuroradiol 2010; 20:5-24. [DOI: 10.1007/s00062-010-9036-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 12/17/2009] [Indexed: 12/16/2022]
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Prieto R, Pascual JM, Gutiérrez R, Santos E. Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature. Acta Neurochir (Wien) 2009; 151:1385-97. [PMID: 19618103 DOI: 10.1007/s00701-009-0439-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 06/11/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease. Functional outcome is particularly uncertain for the small group of patients that are unable to stand at the time of diagnosis (grade 5 gait disturbance on the Aminoff-Logue scale, ALS). The objective of this study is to examine the final functional outcome of patients with SDAVF in grade 5 gait ALS before treatment. METHODS We conducted a PubMed search using the keyword "spinal dural arteriovenous fistula." A review of the clinical series and single well-detailed case reports of SDAVF gathered 106 patients with grade 5 gait ALS on the initial examination. Additionally, we report the case of a 56-year-old man presenting acute paraplegia and urinary retention on admission who had complained of sporadic motor and sphincter disturbances for 1 year. Spine T2-weighted MR imaging showed a central hyperintensity within the spinal cord, and the angiography demonstrated a T-11 SDAVF. Interruption of the fistula was performed through an urgent one-level laminectomy. RESULTS Grade 5 gait ALS was present in 25% of the patients with SDAVF included in the clinical series. Latest follow-up showed that gait disturbance improved in 73% of patients after treatment, although less than 6% became grade 1 gait ALS. Micturition disturbances improved in 39%. Exploration of our patient showed improvement to grade 1 gait ALS 1 year after the surgical treatment. CONCLUSION Interruption of SDAVF in paraplegic patients may improve the final functional gait outcome in some cases. No complete recovery (grade 0 gait ALS) was achieved after treatment. Micturition disturbances had a worse prognosis than motor deficits.
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Affiliation(s)
- Ruth Prieto
- Department of Neurosurgery, Clinico San Carlos University Hospital, 28040 Madrid, Spain.
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Krings T, Lasjaunias P, Geibprasert S, Hans F, Thron A, TerBrugge K, Reinges M. Classification of Spinal Vascular Malformations. Neuroradiol J 2009. [DOI: 10.1177/19714009090220s118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Spinal vascular malformations are rare diseases with a wide variety of neurological presentations. Their classification depends on the differentiation of shunting versus non-shunting lesions, the latter being the spinal cord cavernomas. In the shunting lesions, the next step in the proposed classification scheme is related to the feeding artery which can subdivide the dural vascular shunts from the pial vascular malformations: while those shunts that are fed by radiculomeningeal arteries (i.e. the counterparts of meningeal arteries in the brain) constitute the dural arteriovenous fistulas, the shunts that are fed by arteries that would normally supply the spinal cord (i.e. the radiculomedullary and radiculopial arteries) are the pial cord arteriovenous malformations (whose cranial counterparts are the brain AVMs). Depending on the type of transition between artery and vein the latter pial AVMs can be further subdivided into glomerular (plexiforme or nidus-type) AVMs with a network of intervening vessels in between the artery and vein and the fistulous pial AVMs. The last step in the classification then describes whether the type of fistula has a high or a low shunting volume which will differentiate the “Macro-” from the “Micro-”fistulae. The proposed classification is therefore based on a stepwise analysis of the shunt including its arterial anatomy, its nidus-architecture and its flow-volume evaluation. The major advantage of this approach is that it leads to a subclassification with direct implications on the choice of treatment, thereby constituting a simple and practical approach to evaluate these rare diseases.
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Affiliation(s)
- T. Krings
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital; Toronto, Ontario, Canada
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, Le Kremlin-Bicetre; Paris, France
- Department of Neuroradiology, University Hospital Aachen; Aachen, Germany
| | - P.L. Lasjaunias
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, Le Kremlin-Bicetre; Paris, France
| | - S. Geibprasert
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, Le Kremlin-Bicetre; Paris, France
- Department of Diagnostic Radiology, the Hospital for Sick Children, University of Toronto; Toronto, Ontario, Canada
| | - F.J. Hans
- Clinic for Neurosurgery, University Hospital Aachen; Aachen Germany
| | - A.K. Thron
- Department of Neuroradiology, University Hospital Aachen; Aachen, Germany
| | - K.G. TerBrugge
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital; Toronto, Ontario, Canada
| | - M.H.T. Reinges
- Clinic for Neurosurgery, University Hospital Aachen; Aachen Germany
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Abstract
Spinal dural arteriovenous (AV) fistulas are the most commonly encountered vascular malformation of the spinal cord and a treatable cause for progressive para- or tetraplegia. They most commonly affect elderly men and are classically found in the thoracolumbar region. The AV shunt is located inside the dura mater close to the spinal nerve root where the arterial blood from a radiculomeningeal artery enters a radicular vein. The increase in spinal venous pressure leads to decreased drainage of normal spinal veins, venous congestion, and the clinical findings of progressive myelopathy. On MR imaging, the combination of cord edema, perimedullary dilated vessels, and cord enhancement is characteristic. Therapy has to be aimed at occluding the shunting zone, either by superselective embolization with a liquid embolic agent or by a neurosurgical approach. Following occlusion of the fistula, the progression of the disease can be stopped and improvement of symptoms is typically observed.
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Affiliation(s)
- T Krings
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital and Hospital for Sick Children, Toronto, Ontario, Canada.
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