Overview of the current role of endovascular and surgical treatment in spinal dural arteriovenous fistulas

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.

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Endovascular management of spinal dural arteriovenous fistulas

Neurosurgical FOCUS ◽

10.3171/2009.2.focus098 ◽

2009 ◽

Vol 26 (5) ◽

pp. E15 ◽

Cited By ~ 46

Author(s):

Walavan Sivakumar ◽

Gabriel Zada ◽

Parham Yashar ◽

Steven L. Giannotta ◽

George Teitelbaum ◽

...

Keyword(s):

Surgical Treatment ◽

Vascular Malformations ◽

Endovascular Embolization ◽

Embolic Agent ◽

Endovascular Management ◽

Arteriovenous Fistulas ◽

Spinal Vascular Malformations ◽

Embolic Agents ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

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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Open and endovascular treatment of spinal dural arteriovenous fistulas: a 10-year experience

Journal of Neurosurgery Spine ◽

10.3171/2016.9.spine16394 ◽

2017 ◽

Vol 26 (4) ◽

pp. 519-523 ◽

Cited By ~ 20

Author(s):

Matthew J. Koch ◽

Christopher J. Stapleton ◽

Pankaj K. Agarwalla ◽

Collin Torok ◽

John H. Shin ◽

...

Keyword(s):

Vascular Malformations ◽

Management Strategies ◽

Case Series ◽

Endovascular Embolization ◽

Definitive Treatment ◽

Type I ◽

Arteriovenous Fistulas ◽

Presenting Symptoms ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

OBJECTIVE Vascular malformations of the spine represent rare clinical entities with profound neurological implications. Previously reported studies on management strategies for spinal dural arteriovenous fistulas (sDAVFs) appeared before the advent of modern liquid embolic agents. Authors of the present study review their institutional experience with endovascularly and surgically treated sDAVFs. METHODS The authors performed a retrospective, observational, single-center case series on sDAVFs treated with endovascular embolization, microsurgical occlusion, or both between 2004 and 2013. The mode, efficacy, and clinical effect of treatment were evaluated. RESULTS Forty-seven patients with spinal arteriovenous malformations were evaluated using spinal angiography, which demonstrated 34 Type I sDAVFs (thoracic 20, lumbar 12, and cervical 2). Twenty-nine of the patients (85%) were male, and the median patient age was 63.3 years. Twenty patients underwent primary endovascular embolization (16 Onyx, 4 N-butyl cyanoacrylate [NBCA]), and 14 underwent primary surgical clipping. At a mean follow-up of 36 weeks, according to angiography or MR angiography, 5 patients treated with endovascular embolization demonstrated persistent arteriovenous shunting, whereas none of the surgically treated patients showed lesion persistence (p = 0.0237). Thirty patients (88%) experienced some resolution of their presenting symptoms (embolization 17 [85%], surgery 13 [93%], p = 1.00). CONCLUSIONS Microsurgical occlusion remains the most definitive treatment modality for sDAVFs, though modern endovascular techniques remain a viable option for the initial treatment of anatomically amenable lesions. Treatment of these lesions usually results in some clinical improvement.

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Spinal epidural arteriovenous fistula with perimedullary drainage

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.5.4.353 ◽

2006 ◽

Vol 5 (4) ◽

pp. 353-358 ◽

Cited By ~ 51

Author(s):

Timo Krings ◽

Michael Mull ◽

Azize Bostroem ◽

Juergen Otto ◽

Franz J. Hans ◽

...

Keyword(s):

Venous Congestion ◽

Resonance Imaging ◽

Rare Type ◽

Arteriovenous Fistulas ◽

Arteriovenous Shunts ◽

Dural Arteriovenous Fistulas ◽

Complete Obliteration ◽

Spinal Dural Arteriovenous Fistulas ◽

Spinal Epidural

✓ The classic angiographically demonstrated features of spinal dural arteriovenous fistulas are shunts of radiculomeningeal branches with radicular veins draining exclusively in the direction of perimedullary veins and thereby causing venous congestion. These shunts are located at the point where the radicular vein passes the dura mater. Spinal epidural arteriovenous shunts, however, normally do not drain into the perimedullary veins and are, therefore, asymptomatic, presumably because of a postulated reflux-impeding mechanism between the dural sleeves. The authors report on a patient in whom an epidural arteriovenous shunt showed delayed retrograde drainage into perimedullary veins, leading to the classic clinical (and magnetic resonance imaging–based) findings of venous congestion. Intraoperatively the angiographically established diagnosis was confirmed. Coagulation of both the epidural shunt zone and the radicular vein resulted in complete obliteration of the fistula, as confirmed on repeated angiography. This rare type of fistula should stimulate considerations on the role of valvelike mechanisms normally impeding retrograde flow from the epidural plexus to perimedullary veins and suggest that, in certain pathological circumstances, epidural fistulas can drain retrogradely into perimedullary veins as an infrequent variant of spinal arteriovenous shunts.

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Endovascular Embolization of a Lateral Sacral Fistula: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa020 ◽

2020 ◽

Vol 19 (3) ◽

pp. E313-E313

Author(s):

Rudy J Rahme ◽

Karl R Abi-Aad ◽

Ahmad Kareem Almekkawi ◽

Devi P Patra ◽

Bernard R Bendok

Keyword(s):

Vascular Malformations ◽

Spastic Paraparesis ◽

Endovascular Embolization ◽

Delay In Diagnosis ◽

Arteriovenous Fistulas ◽

Key Points ◽

Dural Arteriovenous Fistulas ◽

Internal Iliac ◽

Spinal Dural Arteriovenous Fistulas

Abstract Spinal dural arteriovenous fistulas are the most common vascular malformations of the spine. They are localized in the sacral spine in 5% to 14% of the cases. They can be fed by the median or the lateral sacral arteries. These lesions present with nonspecific symptoms such as radiculopathy and/or myelopathy, which often leads to a delay in diagnosis. In this video, we present the case of a 65-yr-old gentleman with a lateral sacral dural arteriovenous fistula. The patient was referred to our institution after the outside facility workup was nondiagnostic. He presented with spastic paraparesis and bilateral radiculopathy. After patient informed consent was obtained, we performed a spinal diagnostic angiogram with catheterization and angiography of the internal iliac artery, which revealed the fistula. Onyx (Medtronic, Dublin, Ireland) embolization was performed, which led to a complete occlusion of the fistula. The patient had complete neurological recovery, and at 2-yr follow-up, imaging remained negative for a fistula. In this video, we discuss the nuances and key points related to the epidemiology, diagnosis, and treatment of lateral sacral fistulas.1-3

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29 Emergent Presentation and Management of Spinal Dural Arteriovenous Fistulas and Vascular Lesions

Neurosurgical Emergencies ◽

10.1055/b-0038-160220 ◽

2018 ◽

Keyword(s):

Vascular Lesions ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

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Progressive Gait Dysfunction

10.1093/med/9780190495541.003.0034 ◽

2016 ◽

Author(s):

Ji Y. Chong ◽

Michael P. Lerario

Keyword(s):

Arteriovenous Malformations ◽

Vascular Malformations ◽

Endovascular Embolization ◽

Arteriovenous Fistulas ◽

Progressive Myelopathy ◽

Spinal Vascular Malformations ◽

Gait Dysfunction ◽

Dural Arteriovenous Fistulas ◽

Neurological Change ◽

Spinal Arteriovenous Malformations

Spinal vascular malformations are rare, with dural arteriovenous fistulas (AVFs) accounting for the majority of the pathology. Unlike spinal arteriovenous malformations, which cause abrupt neurological change as a result of hemorrhage, spinal dural AVFs tend to result in a progressive myelopathy through venous congestion and cord edema. If diagnosed and treated early with endovascular embolization or microsurgery, some deficits may be reversible.

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Endovascular and Surgical Treatment of Spinal Dural Arteriovenous Fistulas: Assessment of Post-treatment Clinical Outcome

Neurologia medico-chirurgica ◽

10.2176/nmc.oa.2015-0100 ◽

2016 ◽

Vol 56 (1) ◽

pp. 27-32 ◽

Cited By ~ 5

Author(s):

Panagiotis ZOGOPOULOS ◽

Hajime NAKAMURA ◽

Tomohiko OZAKI ◽

Katsunori ASAI ◽

Hiroyuki IMA ◽

...

Keyword(s):

Surgical Treatment ◽

Clinical Outcome ◽

Post Treatment ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

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Endovascular and surgical treatment of spinal dural arteriovenous fistulas

Neuroradiology ◽

10.1007/s00234-008-0425-3 ◽

2008 ◽

Vol 50 (10) ◽

pp. 869-876 ◽

Cited By ~ 60

Author(s):

Robert H. Andres ◽

Alain Barth ◽

Raphael Guzman ◽

Luca Remonda ◽

Marwan El-Koussy ◽

...

Keyword(s):

Surgical Treatment ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

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Rare association between spinal dural arteriovenous fistulas and dysraphisms: Report of two cases and review of the literature with a focus on pitfalls in diagnosis and treatment

Interventional Neuroradiology ◽

10.1177/1591019917714636 ◽

2017 ◽

Vol 23 (5) ◽

pp. 458-464 ◽

Cited By ~ 5

Author(s):

Giacomo Talenti ◽

Giovanni Vitale ◽

Giacomo Cester ◽

Alessandro Della Puppa ◽

Roberto Faggin ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Vascular Malformations ◽

Diagnosis And Treatment ◽

Review Of The Literature ◽

Arteriovenous Fistulas ◽

Rare Association ◽

Spinal Vascular Malformations ◽

Dural Arteriovenous Fistulas ◽

Spinal Arteriovenous Malformations ◽

Spinal Dural Arteriovenous Fistulas

Spinal vascular malformations are uncommon yet important spinal pathologies commonly classified in congenital and acquired lesions. Spinal lipomas consist of three subtypes: intramedullary lipomas, lipomyelo(meningo)celes and lipomas of the filum. Although the association of spinal arteriovenous malformations (AVM) with other congenital anomalies is well known, the coexistence of dural arteriovenous fistulas (AVF) and tethered spinal cord is exceptionally rare and only eight cases have been reported. We present two cases from our institution and speculate on the possible origin of such a rare but insidious association. We review the current literature with a focus on possible pitfalls in diagnosis and treatment.

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