Magnetic resonance imaging findings in treated spinal dural arteriovenous fistulas: lack of correlation with clinical outcomes

Object Little information is available on follow-up MR imaging after treatment of spinal dural arteriovenous fistulas (DAVFs). The authors studied MR imaging findings in treated spinal DAVFs in relation to clinical outcomes. Methods A retrospective review of patients with spinal DAVFs who had undergone both pre- and postoperative spinal MR imaging was conducted. Postoperative MR images were obtained as routine follow-up studies or because of subjective or objective clinical deterioration. Several pre- and posttreatment MR imaging characteristics were evaluated by 2 neuroradiologists blinded to the clinical outcome. Clinical outcomes of motor, sensory, and urinary function (in relation to the patient's preoperative status) at the time of the postoperative MR imaging were obtained from the clinical record. The chi-square, Fisher exact, and rank-sum tests were performed to correlate imaging findings and changes with clinical outcomes. Results Thirty-four patients met inclusion criteria. Treatment was surgical in 33 patients and endovascular in 1 patient. Follow-up MR imaging was performed at a mean 168 ± 107 days after treatment. Twenty-seven patients (79.4%) were either clinically stable or improved, and 7 (20.6%) experienced worsening in one or more clinical outcomes. Most patients were found to have improvement of MR imaging changes. However, some degree of persistent spinal cord signal abnormality, enhancement, and swelling was observed in 31 (91.2%), 29 (85.3%), and 18 (52.3%) patients, respectively. Changes in these MR imaging characteristics compared with preoperative MR imaging did not correlate with clinical outcomes (p > 0.05), with the one exception of a significant correlation between change in urinary function and extent of spinal cord contrast enhancement (p = 0.026), a correlation of uncertain importance. Ten of the 34 patients underwent posttreatment digital subtraction angiography, and 3 of these patients had recurrent/residual DAVFs. Worsening of motor function significantly correlated with recurrent/residual DAVF (p = 0.053). Conclusions Spinal cord abnormalities persist on postoperative MR imaging studies in patients with treated spinal DAVFs, and although they tend to mildly improve with time, these changes may not correlate with clinical outcomes. However, regardless of imaging findings, worsening motor function may correlate with a recurrent or residual DAVF.

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Sacral dural arteriovenous fistulas: a diagnostic and therapeutic challenge – single-centre experience of 13 cases and review of the literature

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013307 ◽

2017 ◽

Vol 10 (4) ◽

pp. 415-421 ◽

Cited By ~ 10

Author(s):

Andrea Gioppo ◽

Giuseppe Faragò ◽

Caterina Giannitto ◽

Luigi Caputi ◽

Andrea Saladino ◽

...

Keyword(s):

Spinal Cord ◽

Clinical Presentation ◽

Vascular Abnormalities ◽

Arteriovenous Fistulas ◽

Endovascular Embolisation ◽

Imaging Characteristics ◽

Dural Arteriovenous Fistulas ◽

Internal Iliac ◽

Clinical Records

BackgroundSacral dural arteriovenous fistulas (DAVFs) are rare vascular abnormalities of the spine characterised by slowly progressive symptoms that can mimic different myelopathy disorders.ObjectTo report our single Institution experience with sacral DAVFs.MethodsWe retrospectively reviewed the clinical records of patients admitted from 1 January 2006 to 31 December 2016 with a diagnosis of sacral DAVFs, treated by endovascular embolisation or surgical clipping. Clinical presentation, imaging characteristics, treatment results and follow-up were analysed.ResultsWe identify 13 patients with sacral DAVFs supplied by lateral sacral arteries. Clinical presentation was characterised by different degrees of motor weakness and sphincter disturbances. In all patients, spinal MRI showed spinal cord hyperintensities with enhancement and prominent perimedullary vessels. Selective internal iliac angiography was mandatory to identify the exact location of the fistula. A complete embolisation was achieved in eight patients performing a single endovascular embolisation and in three patients performing a single surgical disconnection: two patients required combined procedures. Follow-up imaging showed a complete resolution of the spinal cord hyperintensities in 81% of patients and a reduction of the intramedullary enhancement in 91%. Gait improvement was observed in 73% of patients, while remaining stable in 27%. Sphincter disturbances improved in 36% of patients and remained stable in 64%.ConclusionAwareness of sacral location of DAVFs is critical because standard spinal angiography will not identify sacral supplies, unless internal iliac arteries are properly examined. In our experience, the endovascular treatment show results comparable to surgery when the fistula point is correctly disconnected.

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Surgical and endovascular treatment of spinal dural arteriovenous fistulas: long-term disability assessment and prognostic factors

Journal of Neurosurgery Spine ◽

10.3171/spi.2001.94.2.0199 ◽

2001 ◽

Vol 94 (2) ◽

pp. 199-204 ◽

Cited By ~ 22

Author(s):

Joon K. Song ◽

Fernando Viñuela ◽

Y. Pierre Gobin ◽

Gary R. Duckwiler ◽

Yuichi Murayama ◽

...

Keyword(s):

Prognostic Factors ◽

Mr Imaging ◽

Symptom Onset ◽

Disability Score ◽

Content Type ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas ◽

Fine Print

Object. The authors assessed clinical outcomes of patients with treated spinal dural arteriovenous fistulas (DAVFs) and investigated prognostic factors. Methods. Thirty consecutive patients with spinal DAVFs were treated at the authors' institution during the past 15 years: seven underwent surgery; seven underwent surgery after failed embolization; and 16 underwent embolization alone. The outcomes of gait and micturition disability were analyzed. Follow up averaged 3.4 years (range 1 month–11.8 years). Age, duration of symptoms, pre- and postintervention magnetic resonance (MR) imaging findings, and preintervention disability were correlated with outcome. Seventeen patients (57%) experienced improved gait, 12 (40%) were unchanged, and one (3%) was worse. In 11 patients (37%) micturition function was improved, in 15 (50%) it was unchanged, and in four (13%) it was worse. Gait disability, as measured by the Aminoff—Logue Scale, was significantly improved after treatment, from 3.4 ± 1.4 (average ± standard deviation) to 2.7 ± 1.5 (p = 0.007). Mean micturition disability scores decreased, but not significantly, from 1.9 ± 1 to 1.6 ± 1.1 (p = 0.20). Preintervention gait disability was not associated with improvement except for patients with Aminoff—Logue Scale Grade 4 disability (eight of nine improved; p = 0.024). For patients treated within 13 months of symptom onset, mean micturition disability decreased (p = 0.035). No association was found between clinical improvement and age, a symptom duration less than 30 months, or pre- and postintervention MR imaging—documented spinal cord edema. Conclusions. Spinal DAVF treatment significantly improved patients' mean gait disability score by almost one grade at last follow up. The mean micturition disability score was not significantly improved, unless treatment was performed within 13 months of symptom onset. Longer and more uniform follow-up study is needed to determine if improved and stabilized clinical outcomes are sustained.

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Clinical Outcomes of Patients with Delayed Diagnosis of Spinal Dural Arteriovenous Fistulas

American Journal of Neuroradiology ◽

10.3174/ajnr.a4504 ◽

2015 ◽

Vol 37 (2) ◽

pp. 380-386 ◽

Cited By ~ 25

Author(s):

W. Brinjikji ◽

D.M. Nasr ◽

J.M. Morris ◽

A.A. Rabinstein ◽

G. Lanzino

Keyword(s):

Clinical Outcomes ◽

Delayed Diagnosis ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

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

Neurosurgical FOCUS ◽

10.3171/2012.1.focus11376 ◽

2012 ◽

Vol 32 (5) ◽

pp. E17 ◽

Cited By ~ 40

Author(s):

Jennifer E. Fugate ◽

Giuseppe Lanzino ◽

Alejandro A. Rabinstein

Keyword(s):

Spinal Cord ◽

Clinical Symptoms ◽

Neurological Deficits ◽

Intramedullary Spinal Cord ◽

Lower Extremity Weakness ◽

Arteriovenous Fistulas ◽

Signal Abnormality ◽

Dural Arteriovenous Fistulas ◽

Sensory Disturbances ◽

Spinal Dural Arteriovenous Fistulas

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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Clinical outcomes and prognostic factors in patients with spinal dural arteriovenous fistulas : a prospective cohort study in two Chinese centres

BMJ Open ◽

10.1136/bmjopen-2017-019800 ◽

2018 ◽

Vol 8 (1) ◽

pp. e019800 ◽

Cited By ~ 5

Author(s):

Yongjie Ma ◽

Sichang Chen ◽

Chao Peng ◽

Chunxiu Wang ◽

Guilin Li ◽

...

Keyword(s):

Prognostic Factors ◽

Clinical Outcomes ◽

Clinical Improvement ◽

Prospective Cohort ◽

Short Term ◽

Duration Of Symptoms ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Neurosurgical Treatment ◽

Spinal Dural Arteriovenous Fistulas

BackgroundThe short-term outcomes and prognostic factors of patients with spinal dural arteriovenous fistulas (SDAVFs) have not been defined in large cohorts.ObjectiveTo define the short-term clinical outcomes and prognostic factors in patients with SDAVFs.MethodsA prospective cohort of 112 patients with SDAVFs were included consecutively in this study. The patients were serially evaluated with the modified Aminoff and Logue’s Scale (mALS) one day before surgery and at 3 months, 6 months and 12 months after treatment. Univariate and multivariate analyses were performed to identify demographic, clinical and procedural factors related to favourable outcome.ResultsA total of 94 patients (mean age 53.5 years, 78 were men) met the criteria and are included in the final analyses. Duration of symptom ranged from 0.5 to 66 months (average time period of 12.7 months). The location of SDAVFs was as follows: 31.6% above T7 level, 48.4% between T7 and T12 level (including T7 and T12) and 20.0% below T12 level. A total of 81 patients (86.2%) underwent neurosurgical treatment, 10 patients (10.6%) underwent endovascular treatment, and 3 patients (3.2%) underwent neurosurgical treatment after unsuccessful embolisation. A total of 78 patients demonstrated an improvement in mALS score of one point or greater at 12 months. Preoperative mALS score was associated with clinical improvement after adjusting for age, gender, duration of symptoms, location of fistula and treatment modality using unconditional logistic regression analysis (p<0.05).ConclusionApproximately four fifths of the patients experienced clinical improvement at 12 months and preoperative mALS was the strongest predictor of clinical improvement in the cohort.

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Volumetric myelographic magnetic resonance imaging to localize difficult-to-find spinal dural arteriovenous fistulas

Journal of Neurosurgery Spine ◽

10.3171/2010.11.spine10328 ◽

2011 ◽

Vol 14 (3) ◽

pp. 398-404 ◽

Cited By ~ 20

Author(s):

Jonathan M. Morris ◽

Timothy J. Kaufmann ◽

Norbert G. Campeau ◽

Harry J. Cloft ◽

Giuseppe Lanzino

Keyword(s):

Magnetic Resonance Imaging ◽

Steady State ◽

Magnetic Resonance ◽

Mr Imaging ◽

Mr Angiography ◽

Three Dimensional ◽

Resonance Imaging ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

Although more prevalent in males in the 6th and 7th decade of life, spinal dural arteriovenous fistulas (SDAVFs) are an uncommon cause of progressive myelopathy. Magnetic resonance imaging and more recently Gd bolus MR angiography have been used to diagnose, radiographically define, and preprocedurally localize the contributing lumbar artery. Three-dimensional myelographic MR imaging sequences have recently been developed for anatomical evaluation of the spinal canal. The authors describe 3 recent cases in which volumetric myelographic MR imaging with a 3D phase-cycled fast imaging employing steady state acquisition (PC-FIESTA) and a 3D constructive interference steady state (CISS) technique were particularly useful not only for documenting an SDAVF, but also for providing localization when CT angiography, MR imaging, MR angiography, and spinal angiography failed to localize the fistula. In a patient harboring an SDAVF at T-4, surgical exploration was performed based on the constellation of findings on the PC-FIESTA images as well as the fact that the spinal segments leading to T-4 were the only ones that the authors were unable to catheterize. In a second patient, who harbored an SDAVF at T-6, after 2 separate angiograms failed to demonstrate the fistula, careful assessment of the CISS images led the authors to focus a third angiogram on the left T-6 intercostal artery and to perform superselective microcatheterization. In a third patient with an SDAVF originating from the lateral sacral branch, the PC-FIESTA sequence demonstrated the arterialized vein extending into the S-1 foramen, leading to a second angiogram and superselective internal iliac injections. The authors concluded that myelographic MR imaging sequences can be useful not only as an aid to diagnosis but also for localization of an SDAVF in complex cases.

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Asymptomatic spinal dural arteriovenous fistulas: pathomechanical considerations

Journal of Neurosurgery Spine ◽

10.3171/2012.2.spine11500 ◽

2012 ◽

Vol 16 (5) ◽

pp. 441-446 ◽

Cited By ~ 19

Author(s):

Kenichi Sato ◽

Karel G. TerBrugge ◽

Timo Krings

Keyword(s):

Spinal Cord ◽

Clinical Symptoms ◽

Dorsal Side ◽

Venous Hypertension ◽

Venous Outflow ◽

Arteriovenous Fistulas ◽

Asymptomatic Patients ◽

Dural Arteriovenous Fistulas ◽

Upper Thoracic ◽

Spinal Dural Arteriovenous Fistulas

Object Spinal dural arteriovenous fistulas (SDAVFs) consist of a shunt with converging feeding vessels arising from radiculomeningeal arteries and draining retrogradely via a radicular vein into the perimedullary veins, thereby causing progressive myelopathy due to venous hypertension in the spinal cord. The purpose of this study was to evaluate the hypothesis that the obstruction of radicular venous outlets could be an additional factor inducing symptomatic venous hypertension due to a decreased outflow in SDAVFs. Methods The authors compared the clinical and imaging findings in patients with asymptomatic SDAVFs identified incidentally at the upper thoracic region with the findings in symptomatic patients who harbored SDAVFs at the same level. Results All symptomatic patients presented with medullary dysfunction. The mean age of patients with asymptomatic SDAVF was 51.5 years, approximately 10 years younger than the patients with symptomatic SDAVF (64.1 years old). Despite the existence of dilated perimedullary vessels in the dorsal side of the spinal cord in all patients, the spinal cord edema seen in symptomatic patients was not detected on the MR images obtained in patients with asymptomatic SDAVF. The spinal angiograms of the asymptomatic patients distinctively demonstrated early radicular venous outflow from affected perimedullary veins to the extradural venous plexus as a potential alternate route for the venous hypertension to be released. Conclusions Obstruction of the radicular venous outflow could be an important factor in inducing spinal congestive edema due to venous hypertension, as well as subsequent clinical symptoms of SDAVFs.

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Prospective cohort study of mild cervical spondylotic myelopathy without surgical treatment

Journal of Neurosurgery Spine ◽

10.3171/2011.8.spine11395 ◽

2012 ◽

Vol 16 (1) ◽

pp. 8-14 ◽

Cited By ~ 36

Author(s):

Masatoshi Sumi ◽

Hiroshi Miyamoto ◽

Teppei Suzuki ◽

Shuichi Kaneyama ◽

Takako Kanatani ◽

...

Keyword(s):

Spinal Cord ◽

Surgical Treatment ◽

Mr Imaging ◽

Cervical Spondylotic Myelopathy ◽

Japanese Orthopaedic Association ◽

Rank Test ◽

Imaging Findings ◽

Significant Difference ◽

The Mean

Object Because the main pathology of cervical spondylotic myelopathy (CSM) is spinal cord damage due to compression, surgical treatment is usually recommended to improve patient symptoms and prevent exacerbation. However, lack of clarity of prognosis in cases that present with insignificant symptoms, particularly those of mild CSM, lead one to question the veracity of this course of action. The purpose of this study was to elucidate the prognosis of mild CSM without surgical intervention by evaluation of clinical symptoms and MR imaging findings. Methods Sixty cases of mild CSM (42 males and 18 females, average age 57.2 years) presenting with scores of 13 or higher on the Japanese Orthopaedic Association (JOA) scale were treated initially by in-bed Good Samaritan cervical traction without surgery. These patients were enrolled between 1995 and 2003 and followed up periodically until the date of myelopathy deterioration or until the end of March 2009. The deterioration of myelopathy was defined as a decline in JOA score to less than 13 with a decrease of at least 2 points. As a prognostic factor, the authors used their classification of spinal cord shapes at their lateral sides on axial T1-weighted MR imaging. “Ovoid deformity” was classified as a situation in which both sides were round and convex, and “angular-edged deformity” where one or both sides exhibited an acute-angled lateral corner. The duration of follow-up was assessed as the tolerance rate of mild CSM using Kaplan-Meier survival analysis and compared between 2 groups classified by MR imaging findings. Furthermore, differences between groups were analyzed by various applications of the log-rank test. Results Of the initial 60 cases, follow-up records existed for 55, giving a follow-up rate of 91.7% (38 males and 17 females, average age 56.1 years). The mean JOA score at end point was 14.1, which was not statistically different from the mean of 14.5 at the initial visit. Deterioration in myelopathy was observed in 14 (25.5%) of 55 cases, whereas 41 (74.5%) of 55 cases maintained mild extent myelopathy without deterioration through the follow-up period (mean 94.3 months). The total tolerance rate of mild CSM was 70%. However, there was a significant difference in the tolerance rate between the cases with angular-edged deformity (58%) and cases with ovoid deformity (95%; p = 0.049). Conclusions The tolerance rate of mild CSM was 70% in this study, which proved that the prognosis of mild CSM without surgical treatment was relatively good. However, the tolerance rate of the cases with angular-edged deformity was 58%. Therefore, surgical treatment should be considered when mild CSM cases show angular-edged deformity on axial MR imaging, even if patients lack significant symptoms.

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Spinal Dural Arteriovenous Fistula Presenting with Myelopathy

Cerebrovascular Neurosurgery ◽

10.1093/med/9780190887728.003.0030 ◽

2019 ◽

pp. 279-286

Author(s):

Vinayak Narayan ◽

Anil Nanda

Keyword(s):

Spinal Cord ◽

Arteriovenous Malformations ◽

Dural Arteriovenous Fistula ◽

Endovascular Embolization ◽

Spinal Dural Arteriovenous Fistula ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Degenerative Spinal Disease ◽

Spinal Arteriovenous Malformations ◽

Spinal Dural Arteriovenous Fistulas

Abstract: Spinal dural arteriovenous fistulas are a rare cause of congestive myelopathy. Symptoms are insidious in onset and may be confused with degenerative spinal disease. MRI characteristically shows edema of the spinal cord with serpiginous flow voids that follow the surface of the spinal cord. Careful evaluation with spinal angiography is required to ensure accurate diagnosis. Spinal dural arteriovenous fistulas differ from spinal arteriovenous malformations in that most fistulas have only a single fistulous point without a nidus. Spinal dural arteriovenous fistulas may be treated successfully with either surgical resection or endovascular embolization depending on their anatomy. Earlier treatment is associated with better outcomes.

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