Embolization Tactics of Spinal Epidural Arteriovenous Fistulas

Purpose: Spinal epidural arteriovenous fistulas (SEDAVFs) show an epidural venous sac often with venous congestive myelopathy (VCM) due to intradural reflux at a remote level to which a transarterial approach would be difficult. We present 12 cases of SEDAVF with VCM and describe 3 main tactics for effective transarterial embolization.Materials and Methods: Among 152 patients with spinal vascular malformations diagnosed in our tertiary hospital between 1993 and 2019, 12 SEDAVF patients with VCM were included. Three different transarterial embolization tactics were applied according to the vascular configuration and microcatheter accessibility. We evaluated treatment results and clinical outcomes before and after treatment.Results: Transarterial embolization with glue (20–30%) was performed in all patients. The embolization tactics applied in 12 patients were preferential flow (n=2), plug-and-push (n=6), and filling of the venous sac (n=4). Total occlusion of the SEDAVF, including intradural reflux, was achieved in 11 (91.7%) of 12 patients, and partial occlusion was achieved in 1 patient. No periprocedural complications were reported. Spinal cord edema was improved in all patients for an average of 18 months after treatment. Clinical functional outcome in terms of the pain, sensory, motor, and sphincter scale and modified Rankin scores improved during a mean 25-month follow-up (6.3 vs. 3.3, P=0.002; 3.6 vs. 2.3, P=0.002, respectively).Conclusion: Endovascular treatment for 12 SEDAVF patients with VCM achieved a total occlusion rate of 91.7% without any periprocedural complication. The combined embolization tactics can block intradural reflux causing VCM, resulting in overall good clinical outcomes.

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Cervical spine dural arteriovenous fistula presenting with congestive myelopathy of the conus

Journal of Neurosurgery Spine ◽

10.3171/2009.4.spine08118 ◽

2009 ◽

Vol 11 (4) ◽

pp. 427-431 ◽

Cited By ~ 17

Author(s):

Sasikhan Geibprasert ◽

Sirintara Pongpech ◽

Pakorn Jiarakongmun ◽

Timo Krings

Keyword(s):

Cervical Spine ◽

Clinical Symptoms ◽

Vascular Malformations ◽

Transarterial Embolization ◽

Conus Medullaris ◽

Imaging Findings ◽

Arteriovenous Fistulas ◽

Spinal Vascular Malformations ◽

Arteriovenous Shunts ◽

Spinal Dural Arteriovenous Fistulas

Spinal dural arteriovenous fistulas (DAVFs) are the spinal vascular malformations that are encountered most often, and they are usually encountered in the lower thoracic region. Cervical spine DAVFs are exceedingly rare and may be difficult to differentiate from radicular arteriovenous malformations, epidural arteriovenous shunts, or perimedullary AVFs. Typical angiographic findings in spinal DAVFs include a slow-flow shunt with converging feeding vessels from radiculomeningeal arteries draining via a radicular vein centripetally into perimedullary veins. The MR imaging findings such as spinal cord edema and perimedullary dilated vessels may be used to direct the spinal angiography that is needed to localize and classify the shunt. When the shunt is distant from the pathological imaging findings, the diagnosis may be difficult to establish, especially when the shunt is present at an atypical location such as the cervical spine. The authors present the case of a 51-year-old man presenting with lower thoracic and conus medullaris congestive edema due to a cervical spine DAVF that was located at the C-5 level. Transarterial embolization with N-butyl cyanoacrylate closed the proximal vein and completely obliterated the fistula. Clinical and imaging follow-up confirmed occlusion of the fistula, with improvement in clinical symptoms.

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Four-dimensional digital subtraction angiography for exploration of spinal cord vascular malformations: preliminary experience

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-015909 ◽

2020 ◽

Vol 13 (1) ◽

pp. 69-74

Author(s):

Frédéric Clarençon ◽

Stéphanie Lenck ◽

Eimad Shotar ◽

Anne-Laure Boch ◽

Etienne Lefevre ◽

...

Keyword(s):

Digital Subtraction Angiography ◽

Vascular Malformations ◽

Venous Drainage ◽

Digital Subtraction ◽

Drainage Pattern ◽

Arteriovenous Fistulas ◽

Spinal Vascular Malformations ◽

Precise Understanding ◽

Spinal Dural Arteriovenous Fistulas ◽

Spinal Epidural

BackgroundThe precise understanding of the angioarchitecture of spinal vascular malformations (SVMs) is often difficult to reach with conventional digital subtraction angiography (DSA). The purpose of our study was to evaluate the potential of four-dimensional DSA (4D-DSA) (Siemens Healthcare) in the exploration of SVMs.MethodsWe retrospectively studied all patients who underwent spinal DSA, including 4D-DSA acquisition, from July 2018 to June 2019 at a single institution. All spinal DSA acquisitions were performed under general anesthesia. 4D-DSA acquisitions were acquired with the protocol '12 s DSA Dyna4D Neuro'. 12 mL of iodixanol 320 mg iodine/mL were injected via a 5 F catheter (1 mL/s during the 12 s 4D-DSA acquisition). Inter-rater (three independent reviewers) and intermodality agreements were assessed.ResultsNine consecutive patients (six men, three women, mean age 55.3±19.8 years) with 10 SVMs (spinal dural arteriovenous fistulas n=3, spinal epidural arteriovenous fistulas n=2, spinal pial arteriovenous fistulas n=2, and spinal arteriovenous malformations n=2; one patient had two synchronous pial fistulas) had spinal DSA, including 4D-DSA acquisition. Inter-rater agreement was good and moderate for the venous drainage pattern and the SVM subtype, respectively. In 9 of 10 cases, the quality of the acquisition was graded as good. Satisfactory concordance between 4D-DSA and the selective microcatheterization was observed in 90% of cases for the location of the shunt point.Conclusion4D-DSA acquisition may be helpful for a better understanding of the angioarchitecture of SVMs. Larger series are warranted to confirm these preliminary results.

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Clinical and angioarchitectural characteristics of spinal vascular malformations of the cervical spine

Journal of Neurosurgery Spine ◽

10.3171/2019.11.spine19798 ◽

2020 ◽

Vol 32 (5) ◽

pp. 755-762 ◽

Cited By ~ 1

Author(s):

Waleed Brinjikji ◽

Elisa Colombo ◽

Giuseppe Lanzino

Keyword(s):

Cervical Spine ◽

Lower Extremity ◽

Clinical Presentation ◽

Vascular Malformations ◽

Case Series ◽

Acute Onset ◽

Lower Extremity Weakness ◽

Arteriovenous Fistulas ◽

Spinal Vascular Malformations ◽

Interventional Neuroradiologist

OBJECTIVEVascular malformations of the cervical spine are exceedingly rare. To date there have been no large case series describing the clinical presentation and angioarchitectural characteristics of cervical spine vascular malformations. The authors report their institutional case series on cervical spine vascular malformations diagnosed and treated at their institution.METHODSThe authors retrospectively reviewed all patients with spinal vascular malformations from their institution from January 2001 to December 2018. Patients with vascular malformations of the cervical spine were included. Lesions were characterized by their angioarchitectural characteristics by an interventional neuroradiologist and endovascular neurosurgeon. Data were collected on clinical presentation, imaging findings, treatment outcomes, and long-term follow-up. Descriptive statistics are reported.RESULTSOf a total of 213 patients with spinal vascular malformations, 27 (12.7%) had vascular malformations in the cervical spine. The mean patient age was 46.1 ± 21.9 years and 16 (59.3%) were male. The most common presentations were lower-extremity weakness (13 patients, 48.1%), tetraparesis (8 patients, 29.6%), and lower-extremity sensory dysfunction (7 patients, 25.9%). Nine patients (33.3%) presented with hemorrhage. Fifteen patients (55.6%) had modified Rankin Scale scores of 0–2 at the time of diagnosis. Regarding angioarchitectural characteristics, 8 patients (29.6%) had intramedullary arteriovenous malformations (AVMs), 5 (18.5%) had epidural arteriovenous fistulas (AVFs), 4 (14.8%) had paraspinal fistulas, 4 (14.8%) had mixed epidural/intradural fistulas, 3 (11.1%) had perimedullary AVMs, 2 (7.4%) had dural fistulas, and 1 patient (3.7%) had a perimedullary AVF.CONCLUSIONSThis retrospective study of 27 patients with cervical spine vascular malformations is the largest series to date on these lesions. The authors found substantial angioarchitectural heterogeneity with the most common types being intramedullary AVMs followed by epidural AVFs, paraspinal fistulas, and mixed intradural/extradural fistulas. Angioarchitecture dictated the clinical presentation as intradural shunts were more likely to present with hemorrhage and acute onset myelopathy, while dural and extradural shunts presented as either incidental lesions or gradually progressive congestive myelopathy.

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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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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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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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Spinal Epidural Arteriovenous Fistula: A Unique Pathway into the Perimedullary Vein

Interventional Neuroradiology ◽

10.1177/159101990901500417 ◽

2009 ◽

Vol 15 (4) ◽

pp. 466-469 ◽

Cited By ~ 12

Author(s):

S.M. Lim ◽

I.S. Choi

Keyword(s):

Epidural Space ◽

Clinical Symptoms ◽

Vascular Malformations ◽

Venous Pressure ◽

Venous Plexus ◽

Previous Surgery ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas ◽

Spinal Epidural

Spinal dural arteriovenous fistulas (AVFs) are rare vascular malformations in the spinal dura, fed by dural branches of the radicular arteries, and drain primarily into intradural venous plexuses. They may cause elevated medullary venous pressure and produce a progressive myelopathy. We describe a case of AVF in the epidural space of the previous surgery site of L3 and it showed a unique complex venous pathway into the perimedullary vein, leading to classic clinical symptoms of venous congestion in the spinal cord. The shunt was draining into bilateral epidural venous plexus and then to the paravertebral veins at the level of L2. The venous outflow entered to the epidural space again and finally refluxed into the intradural perimedullary vein.

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Balloon-assisted transarterial embolization of type 1 spinal dural arteriovenous fistula

Neurosurgical FOCUS ◽

10.3171/2014.v2.focus14175 ◽

2014 ◽

Vol 37 (v1supplement) ◽

pp. 1

Author(s):

Brian Lee ◽

Vivek A. Mehta ◽

William J. Mack ◽

Matthew S. Tenser ◽

Arun P. Amar

Keyword(s):

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Vascular Malformations ◽

Transarterial Embolization ◽

Mri Imaging ◽

Spinal Dural Arteriovenous Fistula ◽

Lower Extremity Weakness ◽

Segmental Artery ◽

Spinal Vascular Malformations

Type 1 spinal dural arteriovenous fistula (dAVF) constitute the vast majority of all spinal vascular malformations. Here we present the case of a 71-year-old male with progressive myelopathy, lower-extremity weakness and numbness, and urinary incontinence. MRI imaging of the thoracic spine demonstrated cord edema, and catheter spinal angiography confirmed a type 1 spinal dAVF. The fistula was supplied by small dural branches of the left L-2 segmental artery. Angiographic cure was achieved with a one-stage procedure in which coils were used to occlude the distal segmental vessels, followed by balloon-assisted embolization with Onyx.The video can be found here: http://youtu.be/8aehJbueH0U.

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Transvenous Coil Embolization of an Intraorbital Arteriovenous Fistula

Neurosurgery ◽

10.1227/neu.0b013e31827242cb ◽

2012 ◽

Vol 72 (1) ◽

pp. E130-E134 ◽

Cited By ~ 13

Author(s):

Richard W. Williamson ◽

Andrew F. Ducruet ◽

R. Webster Crowley ◽

Cameron G. McDougall ◽

Felipe C. Albuquerque

Keyword(s):

Coil Embolization ◽

Ophthalmic Artery ◽

Vascular Malformations ◽

Transarterial Embolization ◽

Rare Type ◽

Arteriovenous Fistulas ◽

Ocular Symptoms ◽

Detachable Coils ◽

Endovascular Coil Embolization ◽

Carotid Cavernous Fistulas

Abstract BACKGROUND AND IMPORTANCE: Purely intraorbital arteriovenous fistulas (AVFs), which are rare vascular malformations that clinically mimic carotid-cavernous fistulas (CCFs), involve a fistula from the ophthalmic artery to 1 of the draining ophthalmic veins. We describe a case of an intraorbital AVF treated with transvenous endovascular coil embolization via the inferior petrosal sinus (IPS) route and review the literature on this rare entity. CLINICAL PRESENTATION: An 81-year-old woman sought treatment after 7 days of progressive left-sided visual acuity loss, chemosis, and lateral rectus palsy. Magnetic resonance imaging demonstrated dilated vascularity in the left orbit raising suspicions for a CCF. Cerebral angiography showed a purely intraorbital AVF with a fistula between the left ophthalmic artery and superior ophthalmic vein (SOV). Transvenous selective catheterization of the fistula was performed by successfully navigating the ipsilateral IPS to the cavernous sinus and SOV. The fistula was then embolized using detachable coils. The patient was discharged the next day. Three weeks after embolization, her ocular symptoms and findings had resolved. CONCLUSION: Intraorbital AVFs are a rare type of AVF that can be treated by direct surgical ligation, transarterial embolization, or transvenous embolization. We successfully navigated the IPS, which is frequently stenotic or occluded secondary to chronically increased fistulous drainage, and utilized this route to embolize the fistula with detachable coils.

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Classification of Spinal Vascular Malformations

The Neuroradiology Journal ◽

10.1177/19714009090220s118 ◽

2009 ◽

Vol 22 (1_suppl) ◽

pp. 97-106

Author(s):

T. Krings ◽

P.L. Lasjaunias ◽

S. Geibprasert ◽

F.J. Hans ◽

A.K. Thron ◽

...

Keyword(s):

Spinal Cord ◽

Rare Diseases ◽

Vascular Malformations ◽

Arteriovenous Fistulas ◽

Spinal Vascular Malformations ◽

Choice Of Treatment ◽

Meningeal Arteries ◽

Brain Avms ◽

The Brain

Spinal vascular malformations are rare diseases with a wide variety of neurological presentations. Their classification depends on the differentiation of shunting versus non-shunting lesions, the latter being the spinal cord cavernomas. In the shunting lesions, the next step in the proposed classification scheme is related to the feeding artery which can subdivide the dural vascular shunts from the pial vascular malformations: while those shunts that are fed by radiculomeningeal arteries (i.e. the counterparts of meningeal arteries in the brain) constitute the dural arteriovenous fistulas, the shunts that are fed by arteries that would normally supply the spinal cord (i.e. the radiculomedullary and radiculopial arteries) are the pial cord arteriovenous malformations (whose cranial counterparts are the brain AVMs). Depending on the type of transition between artery and vein the latter pial AVMs can be further subdivided into glomerular (plexiforme or nidus-type) AVMs with a network of intervening vessels in between the artery and vein and the fistulous pial AVMs. The last step in the classification then describes whether the type of fistula has a high or a low shunting volume which will differentiate the “Macro-” from the “Micro-”fistulae. The proposed classification is therefore based on a stepwise analysis of the shunt including its arterial anatomy, its nidus-architecture and its flow-volume evaluation. The major advantage of this approach is that it leads to a subclassification with direct implications on the choice of treatment, thereby constituting a simple and practical approach to evaluate these rare diseases.

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