Timing, severity of deficits, and clinical improvement after surgery for spinal dural arteriovenous fistulas

OBJECTIVESpinal dural arteriovenous fistulas (dAVFs) are rare vascular abnormalities caused by arteriovenous shunting. They often form at the dural root sleeve between a radicular feeding artery and draining medullary vein causing venous congestion and edema, decreased perfusion, and ischemia of the spinal cord. Treatment consists of either surgical ligation of the draining vein or selective embolization via an endovascular approach. There is a paucity of data on which modality provides more durable and effective outcomes.METHODSThe authors performed a retrospective review of a prospectively maintained database by the senior author to assess clinical outcomes in patients undergoing surgical treatment of spinal dAVFs. Preoperative and postoperative motor and Aminoff-Logue Scale (ALS) scores were collected.RESULTSA total of 41 patients with 44 spinal dAVFs were identified, with a mean patient age of 64 years. The mean symptom duration was 14 months, with weakness (82%), urinary symptoms (47%), and sensory symptoms (29%) at presentation. The fistula locations were as follows: 30 thoracic, 9 lumbar, 3 sacral, and 2 cervical. Five patients had normal motor and ALS scores at presentation. Among the remaining 36 patients with motor deficits or abnormal gait and micturition at presentation, 78% experienced an improvement while the remaining 22% continued to be stable. There was a trend toward improved outcomes in patients with shorter symptom duration; mean symptom duration among patients with clinical improvement was 13 months compared with 22 months among those without improvement. Additionally, rates of improvement were higher for lower thoracic and lumbosacral dAVFs (85% and 83%) compared with those in the upper thoracic spine (57%). No patient developed recurrent fistulas or worsening neurological deficits.CONCLUSIONSSurgery is associated with excellent outcomes in the treatment of spinal dAVFs. Early diagnosis and treatment are critical, with a trend toward improved outcomes. No patient in this study had fistula recurrence or worsening of symptoms. Among patients with abnormal motor or ALS scores, 78% improved after surgery. Therapeutic embolization is an option for some lesions, but for cases with unfavorable anatomy where embolization is not feasible, surgery is a safe option associated with high success.

Download Full-text

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.

Download Full-text

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.

Download Full-text

Surgical treatment of Type I spinal dural arteriovenous fistulas

Neurosurgical FOCUS ◽

10.3171/2012.1.focus11344 ◽

2012 ◽

Vol 32 (5) ◽

pp. E3 ◽

Cited By ~ 25

Author(s):

Alexander E. Ropper ◽

Bradley A. Gross ◽

Rose Du

Keyword(s):

Low Flow ◽

Bladder Function ◽

Neurological Deficits ◽

Type I ◽

Microsurgical Treatment ◽

Arteriovenous Fistulas ◽

Presenting Symptoms ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas ◽

Epidemiological Characteristics

Object Type I spinal dural arteriovenous fistulas (SDAVFs) are low-flow vascular shunts fed by radicular arteries in patients who most often present with myelopathy. Although some fistulas are amenable to endovascular embolization, nearly all can be treated with direct microsurgical obliteration. Methods The authors reviewed their experience in treating 214 craniospinal arteriovenous malformations and/or fistulas over the last 8 years. Of these, 19 were spinal (9%), of which 15 (79%) were Type I SDAVFs. The authors reviewed the patients' epidemiological characteristics, presenting symptoms, and SDAVF angioarchitecture in all cases. They subsequently analyzed surgical obliteration rates and outcomes of all 11 patients who underwent fistula microsurgical obliteration. Results In all patients who underwent microsurgical treatment, complete angiographic obliteration of the fistula was achieved. At follow-up, 10 (91%) of 11 patients exhibited improvement, 1 patient (9%) was the same, and no patients were worse. Specifically, 8 (73%) of 11 patients had improvement in strength and sensation, 5 (71%) of 7 had improvement of bowel/bladder function, and 3 (60%) of 5 had improvement of preoperative paresthesias. There were no wound infections, CSF leaks, or permanent neurological deficits. Conclusions Microsurgical treatment of SDAVF provides direct access to the fistula point, allowing for high obliteration rates with excellent long-term improvement of preoperative deficits and limited periprocedural complications.

Download Full-text

Long-term outcomes and prognostic factors in patients with treated spinal dural arteriovenous fistulas: a prospective cohort study

BMJ Open ◽

10.1136/bmjopen-2020-047390 ◽

2022 ◽

Vol 12 (1) ◽

pp. e047390

Author(s):

Chengbin Yang ◽

Yongjie Ma ◽

An Tian ◽

Jiaxing Yu ◽

Sichang Chen ◽

...

Keyword(s):

Cohort Study ◽

Prognostic Factors ◽

Clinical Improvement ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Neurosurgical Treatment ◽

Spinal Dural Arteriovenous Fistulas

ObjectiveTo define the pattern of long-term clinical outcomes and prognostic factors in patients with spinal dural arteriovenous fistulas (SDAVFs).DesginProspective cohort study based on constantly recruiting patients with SDAVFs in two medical centres in China.SettingPatients with SDAVFs were recruited consecutively between March 2013 and December 2014 in two referral centres.ParticipantsA prospective cohort of 94 patients with SDAVFs was included in this study, and 86 patients (mean age 53.0 years, 71 men) completed the study. Patients who had previously undergone endovascular or neurosurgical treatment or had neurological dysfunction caused by other diseases or refused treatment were excluded.InterventionsAll patients underwent neurosurgery or endovascular embolisation. These patients were evaluated with the modified Aminoff and Logue’s Scale (mALS) 1 day before and 3, 6, 12 and 72 months after treatments.ResultsThe duration of symptoms ranged from 0.5 to 66 months (average 12.8 months). The location of SDAVFs was as follows: 33.7% above T7, 50.0% between/include T7 and T12% and 16.3% below T12. 75 patients (87.2%) underwent neurosurgical treatment, and 9 patients (10.5%) underwent endovascular treatment. 58 patients (67.4%) exhibited an improvement in mALS of one point or greater at 72 months. Patients with less disability were more likely to improve at 72 months (p<0.05). 48 patients (55.8%) showed deterioration at 72 months compared with 12 months. 61% of the patients suffered numbness, and 22% had pain before treatment. However, 81% of patients had numbness, and 28% had pain after treatment. This deterioration was related to 1-year mALS and age.ConclusionNearly two-thirds of the patients experienced clinical improvement at 72 months, and preoperative (1 day before treatment) mALS was the strongest predictor of clinical improvement. However, 55.8% of patients showed deterioration after temporary recovery. All patients with SDAVFs should accept treatment as soon as possible.

Download Full-text

Neurosurgical versus endovascular treatment of spinal dural arteriovenous fistulas: a multicenter study of 195 patients

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20309 ◽

2020 ◽

pp. 1-8

Author(s):

Keisuke Takai ◽

Toshiki Endo ◽

Takao Yasuhara ◽

Toshitaka Seki ◽

Kei Watanabe ◽

...

Keyword(s):

Risk Factors ◽

Treatment Failure ◽

Endovascular Treatment ◽

Initial Treatment ◽

Treatment Success ◽

Symptom Duration ◽

Treatment Groups ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

OBJECTIVEThe purpose of the present study was to compare the treatment success rates of primary neurosurgical and endovascular treatments in patients with spinal dural arteriovenous fistulas (dAVFs).METHODSData from 199 consecutive patients with thoracic and lumbosacral spinal dAVFs were collected from 18 centers. Angiographic and clinical findings, the rate of initial treatment failure or recurrence by procedures, risk factors for treatment failure, complications, and neurological outcomes were statistically analyzed.RESULTSSpinal dAVFs were frequently detected in the thoracic region (81%), fed by a single feeder (86%), and shunted into an intradural vein via the dura mater. The fistulous connection between the feeder(s) and intradural vein was located at a single spinal level in 195 patients (98%) and at 2 independent levels in 4 patients (2%). Among the neurosurgical (n = 145), and endovascular (n = 50) treatment groups of single dAVFs (n = 195), the rate of initial treatment failure or recurrence was significantly higher in the index endovascular treatment group (0.68% and 36%). A multivariate analysis identified endovascular treatment as an independent risk factor with significantly higher odds of initial treatment failure or recurrence (OR 69; 95% CI 8.7–546). The rate of complications did not significantly differ between the two treatment groups (4.1% for neurosurgical vs 4.0% for endovascular treatment). With a median follow-up of 26 months, improvements of ≥ 1 point in the modified Rankin Scale (mRS) score and Aminoff-Logue gait and Aminoff-Logue micturition grades were observed in 111 (56%), 121 (61%), and 79 (40%) patients, respectively. Independent risk factors for lack of improvement in the Aminoff-Logue gait grades were multiple treatments due to initial treatment failure or recurrence (OR 3.1) and symptom duration (OR 1.02).CONCLUSIONSBased on data obtained from the largest and most recently assessed multicenter cohort, the present study shows that primary neurosurgery is superior to endovascular treatment for the complete obliteration of spinal dAVFs by a single procedure.

Download Full-text