Elsevier

World Neurosurgery

Volume 83, Issue 6, June 2015, Pages 1002-1005
World Neurosurgery

Original Article
Surgical Treatment of Spinal Dural Arteriovenous Fistula: Management and Long-Term Outcome in a Single-Center Series

https://doi.org/10.1016/j.wneu.2015.02.026Get rights and content

Objective

To perform a retrospective chart review of surgically treated patients with spinal dural arteriovenous fistula (SDAVF), a rare disease but the most common vascular malformation of the spine, focusing on clinical characteristics and functional outcome during long-term follow-up.

Methods

Between June 1990 and April 2012, 29 patients with SDAVFs were treated surgically in a single institution. Patient characteristics, time from onset of symptoms to treatment, radiologic features, treatment-related complications, and functional outcome were analyzed. Outcome was assessed according to the Aminoff-Logue scale during follow-up. Results of magnetic resonance imaging scans performed during long-term follow-up were correlated with functional outcome.

Results

There were 3 female (10%) and 26 male (90%) patients with SDAVFs treated surgically. Mean age was 61 years ± 11. Location of the fistula was at the thoracic level in 20 patients (69%), at the lumbar level in 8 patients (28%), and at the sacral level in 1 patient (3%). Mean postoperative Aminoff-Logue scale scores regarding gait and micturition improved after treatment compared with preoperatively (P = 0.02; P = 0.03). After surgical treatment, 22 patients (76%) achieved improvement in neurologic symptoms. In 6 patients (21%), neurologic status was the same as preoperatively. In 1 patient (3%), neurologic status worsened. Medullary signal alteration of diagnostic magnetic resonance imaging scans did not correlate with functional outcome (P = 0.2). Mean follow-up time was 63 months ± 55. All SDAVFs were treated in a single session without recurrence during the long-term follow-up period.

Conclusions

Surgical treatment of SDAVFs is safe and effective and leads to an improvement of neurologic symptoms in most patients. Surgical treatment of SDAVFs also provides long-term stability.

Introduction

Spinal dural arteriovenous fistulas (SDAVFs) consist of an abnormal shunt between a dural artery branch and a radicular vein, leading to increased pressure in the venous system with consecutive venous congestion. Despite its rarity, SDAVF is the most common type of spinal vascular malformation. Patients often experience nonspecific symptoms (9). However, favorable outcome depends on the progression of neurologic deficits at the time of diagnosis, which makes early diagnosis preferable (10). Surgical disruption of the pathologic arteriovenous junction is considered to be a straightforward treatment modality for SDAVF 1, 14, 16. Advanced endovascular treatment modalities have been considered as feasible alternatives 13, 15, 17, 18. However, low perioperative risk and barely any recurrence of SDAVF after treatment are reported advantages of surgical occlusion 1, 6, 8, 14, 16. We analyzed long-term results in regard to radiologic and clinical outcome after surgical treatment of SDAVF in our institution.

Section snippets

Patients

Between June 1990 and April 2012, 29 consecutive patients with SDAVFs were treated surgically at our institution. SDAVFs were diagnosed with magnetic resonance imaging (MRI), magnetic resonance angiography, and spinal angiography. Patient characteristics on admission and during the treatment course, clinical presentation, duration of symptoms, radiologic features, and functional neurologic outcome were analyzed. The treatment decision concerning the SDAVF was based on an interdisciplinary

Patient Characteristics

Patient characteristics, including age, gender, angiographic and radiologic findings, and clinical outcome, are summarized in Table 1. There were 29 patients with SDAVFs treated surgically at our institution. The present series consists of 3 female (10%) and 26 male (90%) patients with a mean age of 61 years ± 11. Overall, favorable functional outcome was achieved in 22 patients (76%). A favorable outcome was achieved in 19 male patients and all 3 female patients during the follow-up period. A

Discussion

SDAVFs often manifest with slow but progressive symptoms of myelopathy (9). Nonspecific symptoms with subtle onset are very common in patients with SDAVFs, which leads to a long time interval from onset of symptoms until diagnosis and subsequent treatment 9, 14. Mean time from onset of neurologic symptoms to surgical treatment was 21 months ± 27 in the present study. These long time intervals are in accordance with previous studies 14, 15, 16, 17. However, patients who achieved a favorable

Conclusions

The present data indicate that surgical treatment of SDAVFs is safe and effective and leads to an improvement of neurologic symptoms in most patients. The data also indicate that surgical treatment provides long-term stability after treatment. SDAVF should be included in the differential diagnosis of every patient presenting with progressive myelopathy to allow timely diagnosis.

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  • Spinal Dural Arteriovenous Fistula: Diagnosis, Outcomes, and Prognostic Factors

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    Notably, our study did not assess the radiographic characteristics of SDAVFs. However, previous studies that investigated the radiographic parameters failed to demonstrate predictive significance.14,16,31 A misdiagnosis has been relatively common for patients with SDAVFs, contributing to a longer symptom duration before treatment.

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    The treatment difficulty and surgical risk when treating spinal AV shunts may be greatly dependent on the lesion subtype and its angioarchitecture. D-AVF is the most common and widely studied type of spinal AV shunt [12–23]. In previous reports, the obliteration rate following direct surgery is very high in D-AVF.

  • Rare Case of Spinal Dural Arteriovenous Fistula with Radiculopathy, without Myelopathy or Spinal Edema on Magnetic Resonance Imaging

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    Pathologically, SDAVFs consist of an abnormal shunt between a dural artery branch and a radicular vein, which leads to increased venous pressure with consecutive venous congestion.6 Thus pathogenesis and clinical manifestation of SDAVFs are often slow; however, progressive symptoms such as myelopathy, gait disturbances, sensory changes, and problems with micturition are noted.6,7 This case also indicated that symptomatic SDAVFs could manifest only flow void without spinal cord edema on MRI.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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