Management of Spinal Dural Arteriovenous Fistulae Using an Interdisciplinary Neuroradiological/Neurosurgical Approach: Experience with 47 Cases

Westphal, Manfred; Koch, Christoph

doi:10.1097/00006123-199909000-00006

Cited by 101 publications

(48 citation statements)

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“…The strong preponderence of male patients is well known [7]. Comparable to other series, in the majority of the dural lesions the AV nidus was in the low-thoracic or lumbar region [12,16]. The direction of predominant venous drainage of most dAVFs was rostral [12].…”

Section: Discussionmentioning

confidence: 83%

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Treatment and outcome of spinal dural arteriovenous fistulas

Schick

Hassler

2002

Eur Spine J

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IntroductionSpinal vascular malformations are rare and often misdiagnosed entities. In principle, we distinguish between three types of spinal vascular malformation: extradural, dural, and intradural [2,6,7,11,12]. The intradural malformations can be separated into perimedullary fistulas and the real intramedullary arteriovenous malformations (AVMs). Intradural AVMs are supplied by spinal-cord supplying arteries, whereas dural malformations are supplied by meningeal arteries as branches of the radicular artery [6,12]. Eighty percent of all spinal AVMs are dural fistulas. In contrast to the probably inborn perimedullary fistulas, dAVFs are most likely acquired [11,12]. The fistula itself is located in the dural layer near the penetration point of the nerve root. Venous drainage runs along the spinal cord veins on the surface of the cord, because the local radicular venous drainage is missing. The high venous pressure is presumed to be the cause of clinical symptoms [2,6,9,11].Abstract Spinal dural arteriovenous fistula (dAVFs) are rare and often misdiagnosed entities. The choice between surgical treatment and embolization remains a matter of debate. We report on the cases of 18 patients (16 men, 2 women) with dAVF, who were treated surgically over an 11-year period. Patient age ranged from 32 to 84 years (mean 60 years). Six patients underwent embolization preoperatively. In three cases, angiography examinations failed to show feeding arteries on first examination at neuroradiological centers. Feeding arteries were at a different level than the fistula point in seven patients, two of them presenting with new anastomoses after embolization. Location of the fistula was midthoracic to lumbar. Seven patients were variously misdiagnosed with tumor, polyneuropathy, Guillain-Barré syndrome, syringomyelia, and knee disease. Clinical history was characterized by slowly progressive and fluctuating deterioration.Initial symptoms were mainly sensory loss and motor weakness, lasting for between 4 and 45 months before diagnosis (mean 15 months). Recurrent fistula after operation was found in one patient. In another patient, control angiography revealed a fistula at another level, and in a third, a fistula on the contralateral side. All three patients underwent reoperation. Temporary clinical deterioration was found in four patients, seven remained unchanged, and seven improved postoperatively. An attempt at embolization should be made following diagnostic angiography. Otherwise, surgery is our recommended treatment for spinal dural fistulas, as it has a lower failure rate. Because of the progressive natural course with severe deficits, we favor an early definitive treatment.

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Section: Discussionmentioning

confidence: 83%

“…In the series of Song et al [14], fistulas recurred in 15% of patients despite the use of a liquid embolization material. Westphal and Koch [16] reported on 12 of 47 patients surgically treated after embolization because of the recruitment of collateral vessels. Eight of 47 patients underwent surgery after unsuccessful embolization.…”

Section: Discussionmentioning

confidence: 99%

Treatment and outcome of spinal dural arteriovenous fistulas

Schick

Hassler

2002

Eur Spine J

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“…7,8,21 Patients with preoperative gait disability scores of 2-3 improve more than those in other grade categories. 6,31 Only 11% of patients who have severe preoperative disability (defined by a total score of 6-8 on the combined Aminoff-Logue disability scale for gait and micturition) have substantial improvement postoperatively, while 78% of those with mild disability (score 0-3) improve, and 29% of those with moderate disability (score of 4-5) improve.…”

Section: Predictors Of Outcomementioning

confidence: 99%

“…The initial success rate of embolization was 69% 22 in 1 recent study and has ranged from 30% to 90% depending on whether penetration of the proximal vein is required. 23,26,31 Recanalization-a complication more often seen in endovascular therapy compared with microsurgical clipping-is another consideration. In 1 recent study of 26 patients treated endovascularly, 19% had recanalization and all had accompanying worsening neurological symptoms.…”

mentioning

confidence: 99%

Clinical presentation and prognostic factors of spinal dural arteriovenous fistulas: an overview

Fugate¹,

Lanzino

Rabinstein³

2012

FOC

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Spinal dural arteriovenous fistulas (AVFs), the most common type of spinal cord vascular malformation, can be a challenge to diagnose and treat promptly. The disorder is rare, and the presenting clinical symptoms and signs are nonspecific and insidious at onset. Spinal dural AVFs preferentially affect middle-aged men, and patients most commonly present with gait abnormality or lower-extremity weakness and sensory disturbances. Symptoms gradually progress or decline in a stepwise manner and are commonly associated with pain and sphincter disturbances. Surgical or endovascular disconnection of the fistula has a high success rate with a low rate of morbidity. Motor symptoms are most likely to improve after treatment, followed by sensory disturbances, and lastly sphincter disturbances. Patients with severe neurological deficits at presentation tend to have worse posttreatment functional outcomes than those with mild or moderate pretreatment disability. However, improvement or stabilization of symptoms is seen in the vast majority of treated patients, and thus treatment is justified even in patients with substantial neurological deficits. The extent of intramedullary spinal cord T2 signal abnormality does not correlate with outcomes and should not be used as a prognostic factor.

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“…20,23,48,50,63 The practice of many institutions, including our own, has therefore been to primarily attempt minimally invasive endovascular embolization and reserve surgical intervention for refractory cases or those not amenable to embolization. 20,46,48,57,65 The success of endovascular treatment is believed to be highly dependent on complete occlusion of the proximal radiculomedullary draining vein and the site of the fistula itself. Various radiographic outcome measures have been used in the past to define endovascular occlusion of a spinal DAVF, depending on whether the draining vein is obliterated 63 or the fistula itself is filled with a liquid embolic agent.…”

Section: Endovascular Treatment Of Spinal Avfsmentioning

confidence: 99%

Endovascular management of spinal dural arteriovenous fistulas

Sivakumar

Zada²,

Yashar³

et al. 2009

FOC

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Object Spinal dural arteriovenous fistulas (DAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy, yet remain inefficiently diagnosed lesions. Over the last several decades, the treatment of spinal DAVFs has improved tremendously due to improvements in neuroimaging, microsurgical, and endovascular techniques. The aim of this paper was to review the existing literature regarding the clinical characteristics, classification, and endovascular management of spinal DAVFs. Methods A search of the PubMed database from the National Library of Medicine and reference lists of all relevant articles was conducted to identify all studies pertaining to spinal DAVFs, spinal dural fistulas, and spinal vascular malformations, with particular attention to endovascular management and outcomes. Results The ability to definitively treat spinal DAVFs using endovascular embolization has significantly improved over the last several decades. Overall rates of definitive embolization of spinal DAVFs have ranged between 25 and 100%, depending in part on the embolic agent used and the use of variable stiffness microcatheters. The majority of recent studies in which N-butyl cyanoacrylate or other liquid embolic agents were used have reported success rates of 70–90%. Surgical treatment remains the definitive option in cases of failed embolization, repeated recanalization, or lesions not amenable to embolization. Clinical outcomes have been comparable to surgical treatment when the fistula and draining vein remain persistently occluded. Improvements in gait and motor function are more likely following successful treatment, whereas micturition symptoms are less likely to improve. Conclusions Endovascular embolization is an increasingly effective therapy in the treatment of spinal DAVFs, and can be used as a definitive intervention in the majority of patients that undergo modern endovascular intervention. A multidisciplinary approach to the treatment of these lesions is required, as surgery is required for refractory cases or those not amenable to embolization. Newer embolic agents, such as Onyx, hold significant promise for future therapy, yet long-term follow-up studies are required.

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Management of Spinal Dural Arteriovenous Fistulae Using an Interdisciplinary Neuroradiological/Neurosurgical Approach: Experience with 47 Cases

Cited by 101 publications

References 10 publications

Treatment and outcome of spinal dural arteriovenous fistulas

Treatment and outcome of spinal dural arteriovenous fistulas

Clinical presentation and prognostic factors of spinal dural arteriovenous fistulas: an overview

Endovascular management of spinal dural arteriovenous fistulas

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