Angiographic Characteristics and Treatment of Cervical Spinal Dural Arteriovenous Shunts

Abstract

SUMMARY: Spinal DAVSs of the cervical level are rare lesions. The purpose of this study is to describe the clinical and angiographic characteristics of cervical spinal DAVSs. From a prospectively collected database including 449 cases of brain and spinal DAVSs, lesions located at the cervical level were selected. The clinical presentation, angiographic characteristics, and treatment outcome were assessed. Twelve cases of spinal DAVSs were identified at the level of the cervical spinal canal (male to female ratio ϭ 8:4; mean age ϭ 56.5 years). Five patients (41.7%) presented with hemorrhage including SAH (n ϭ 4) and cerebellar hemorrhage (n ϭ 1). Coincidental spinal DAVSs with cranial DAVSs or brain AVMs were noted in 5 cases (41.7%). The spinal DAVS was the symptomatic lesion in 10 cases and was incidentally discovered during evaluation for SAH from a coincidental lesion in 2 cases. Combined endovascular and surgical resection resulted in symptomatic improvement in 10 patients. In conclusion, DAVSs of the cervical spine are rare lesions which often present with hemorrhage and are frequently associated with complex coincidental vascular lesions. Combined endovascular and surgical treatment will result in good outcome.ABBREVIATIONS: APA ϭ ascending pharyngeal artery; ASA ϭ anterior spinal artery; AVF ϭ arteriovenous fistula; AVM ϭ arteriovenous malformation; br ϭ branch; Caud ϭ caudal; Cbll ϭ cerebellar; CostoCerv ϭ costocervical artery; DAVS ϭ dural arteriovenous shunt; DSA ϭ digital subtraction angiography; FU ϭ follow-up; hem ϭ hemorrhage; ICA ϭ internal cerebral artery; Lt ϭ left; min ϭ minimal; NA ϭ not available; n-BCA ϭ n-butyl 2-cyanoacrylate; OA ϭ occipital artery; PVA ϭ polyvinyl alcohol; Rost ϭ rostral; Rt ϭ right; SCA ϭ superior cerebral artery; SAH ϭ subarachnoid hemorrhage; SupPetSin ϭ superior petrosal sinus; ThCerv ϭ thyrocervical artery; Tsin ϭ transverse sinus; VA ϭ vertebral artery S pinal DAVS is a disease in which an abnormal arteriovenous communication develops between the dural branch of a radicular artery and a radicular or leptomeningeal vein along the dura.1 It is by far the most common spinal arteriovenous shunt, typically characterized by presentation beyond the fourth or fifth decade with male predominance and venous congestive myelopathy. The most prevalent location is along the thoracolumbar spine, with rare occurrence in the cervical level.2 This disproportionate distribution has been attributed to the differences of venous drainage patterns. The thoracolumbar cord drains via small-caliber radiculospinal veins, which may make venous drainage somewhat tenuous and sensitive to hemodynamic alterations. In contrast, the venous drainage at the cervical level is more divergent and, therefore, may be less susceptible to the development of various vascular lesions.2 Literature regarding cervical spinal DAVSs is limited to a few case series. 3-6The purpose of this study was to assess the clinical and angiographic characteristics of cervical spinal DAVSs from a large prospectively collected s...

High cervical arteriovenous fistulas fed by dural and spinal arteries and draining into a single medullary vein

“…18,19,38 In a recent report of cervical dural AVFs, an angiographic cure was achieved with N-butyl 2-cyanoacrylate (NBCA) in 2 patients, and resection was performed in 7 patients because of embolization failure or residual and/or recurrent shunt. 15 Embolization plays an important role in the management of Type II and Type III AVMs, either as a primary treatment or as an adjunct to surgery. 1,19,28,30,38 The indications for endovascular treatment of Type IV AVMs vary according to the subtype.…”

Endovascular embolization for symptomatic perimedullary AVF and intramedullary AVM: a series and a literature review

“…Sometimes, selective iliac angiogram is necessary to demonstrate spinal arteriovenous malformations when conventional methods fail to show lesions. The more frequent spinal dural AVFs of the 50-80 years old patients is a probably acquired lesion which is presented in a separate paper [5][6][7]. However, dural fistulas never bleed and clinical deterioration is slow [40].…”

“…However, dural fistulas never bleed and clinical deterioration is slow [40]. Therapy with endovascular techniques or microsurgery is relatively safe [5][6][7]. Perimedullary AVF and intramedullary AVM mostly deteriorate quickly because of hemodynamic or hemorrhagic problems [41].…”

“…vascular malformations [5][6][7]. Dural AVF has its shunt at the dura and can be treated with either surgery or embolization with liquid adhesive.…”

A Patient with a Dural Arteriovenous Fistula at the Craniocervical Junction in Whom Endovascular Treatment Was Initially Performed, Followed by Surgical Management

“…Patients with both perimedullary and dural AVF have been reported. 6,7) A shunting point on images is diagnosed based on rapid changes in the vascular diameter, 6,8) but such a change of the vascular diameter is difficult to identify in some cases. In the present case, the shunting point could be more accurately evaluated by 3D DSA after embolization.…”