Interactive spinal computed tomography angiography–guided spinal digital subtraction angiography and embolization for thoracolumbar epidural arteriovenous fistulas: illustrative case

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  • 1 Department of Neurosurgery, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
  • | 2 Department of Neurosurgery, Hikone Chuo Hospital, Hikone City, Japan; and
  • | 3 Department of Rehabilitation, Hikari Hospital, Saikawa Otsu City, Japan
Open access

BACKGROUND

Spinal digital subtraction angiography (sDSA) is the gold standard for examining spinal arteriovenous fistulas; however, thorough sDSA evaluations of spinal arteriovenous fistulas require a long procedure, which may increase the radiation exposure time.

OBSERVATIONS

A 72-year-old man presented with progressive myelopathy due to a spinal epidural arteriovenous fistula. Spinal computed tomography angiography (sCTA) showed an epidural arteriovenous fistula fed by the left L3 segmental artery. To prepare for sDSA, the sCTA images were modified to mark the segmental artery bifurcations from T5 to L5 with multicolored markers. These modified sCTA images were loaded onto the multiwindow DSA display. The sCTA images were interactively modulated during sDSA. This sCTA-guided sDSA identified 18 segmental arteries within 47 minutes. The total radiation exposure was 1,292 mGy. Subsequently, transarterial embolization resolved the epidural arteriovenous fistula with clinical improvement.

LESSONS

Three-dimensional sCTA can provide detailed anatomical information before sDSA. Modified sCTA images with segmental artery bifurcation marking can provide interactive guidance on multipanel DSA displays. sCTA-guided sDSA is useful for accurate catheterization and reduction of procedure time.

ABBREVIATIONS

3D = three-dimensional; MRI = magnetic resonance imaging; sCTA = spinal computed tomography angiography; sDSA = spinal digital subtraction angiography

BACKGROUND

Spinal digital subtraction angiography (sDSA) is the gold standard for examining spinal arteriovenous fistulas; however, thorough sDSA evaluations of spinal arteriovenous fistulas require a long procedure, which may increase the radiation exposure time.

OBSERVATIONS

A 72-year-old man presented with progressive myelopathy due to a spinal epidural arteriovenous fistula. Spinal computed tomography angiography (sCTA) showed an epidural arteriovenous fistula fed by the left L3 segmental artery. To prepare for sDSA, the sCTA images were modified to mark the segmental artery bifurcations from T5 to L5 with multicolored markers. These modified sCTA images were loaded onto the multiwindow DSA display. The sCTA images were interactively modulated during sDSA. This sCTA-guided sDSA identified 18 segmental arteries within 47 minutes. The total radiation exposure was 1,292 mGy. Subsequently, transarterial embolization resolved the epidural arteriovenous fistula with clinical improvement.

LESSONS

Three-dimensional sCTA can provide detailed anatomical information before sDSA. Modified sCTA images with segmental artery bifurcation marking can provide interactive guidance on multipanel DSA displays. sCTA-guided sDSA is useful for accurate catheterization and reduction of procedure time.

ABBREVIATIONS

3D = three-dimensional; MRI = magnetic resonance imaging; sCTA = spinal computed tomography angiography; sDSA = spinal digital subtraction angiography

BACKGROUND

Spinal digital subtraction angiography (sDSA) is the gold standard for examining spinal arteriovenous fistulas; however, thorough sDSA evaluations of spinal arteriovenous fistulas require a long procedure, which may increase the radiation exposure time.

OBSERVATIONS

A 72-year-old man presented with progressive myelopathy due to a spinal epidural arteriovenous fistula. Spinal computed tomography angiography (sCTA) showed an epidural arteriovenous fistula fed by the left L3 segmental artery. To prepare for sDSA, the sCTA images were modified to mark the segmental artery bifurcations from T5 to L5 with multicolored markers. These modified sCTA images were loaded onto the multiwindow DSA display. The sCTA images were interactively modulated during sDSA. This sCTA-guided sDSA identified 18 segmental arteries within 47 minutes. The total radiation exposure was 1,292 mGy. Subsequently, transarterial embolization resolved the epidural arteriovenous fistula with clinical improvement.

LESSONS

Three-dimensional sCTA can provide detailed anatomical information before sDSA. Modified sCTA images with segmental artery bifurcation marking can provide interactive guidance on multipanel DSA displays. sCTA-guided sDSA is useful for accurate catheterization and reduction of procedure time.

Spinal epidural arteriovenous fistulas and rare arteriovenous shunts are observed in the thoracolumbar region, and they manifest as back pain, progressive radiculopathy, and myelopathy.1 Surgical treatments for spinal epidural arteriovenous fistulas include direct surgery interrupting drainage veins, endovascular embolization of arteriovenous shunts, and a combination of direct surgery and endovascular mbolization.1 Preoperative examinations include gadolinium-enhanced magnetic resonance imaging (MRI), spinal computed tomography angiography (sCTA), and spinal digital subtraction angiography (sDSA).2–5 sDSA is the gold standard for evaluating spinal epidural arteriovenous fistulas,6 and it can identify feeding arteries, which are often bilateral and multilevel.1,3,7,8 However, thorough angiographic evaluation of the bilateral multilevel spinal segmental arteries increases procedure time and radiation exposure dose. Here, we present a technical note on sCTA image-guided sDSA. Composited sCTA images on a multiwindow DSA display can facilitate the angiographic procedure. We present a case of spinal epidural arteriovenous fistula treated using sCTA image-guided sDSA technique.

Illustrative Case

History and Examination

A 72-year-old man presented with bilateral toe numbness lasting for more than a year and reduced walking ability. The patient also had bowel and bladder incontinence and impotence. Thoracic and lumbar MRI revealed thoracolumbar spinal cord edema and multiple vascular flow void signs (Fig. 1). sCTA was performed for further evaluation of the arteriovenous shunt. Subsequently, sDSA was performed.

FIG. 1.
FIG. 1.

Preoperative radiological images. A: Sagittal short tau inversion recovery MRI sequence shows spinal cord edema from the T6 to T12 level. The conus medullaris is also edematous. Multiple flow voids are identified. B: Sagittal CTA image shows vascular enhancement on the ventral and dorsal surface of the thoracolumbar spinal cord.

Spinal CTA-guided Spinal DSA

Three-dimensional (3D) sCTA imaging data were transferred to a medical imaging workstation (Synapse Vincent, Fujifilm). sCTA revealed a spinal epidural arteriovenous fistula fed by the left L3 segmental artery. Vascular images of the T5–L5 segmental arteries and spinal dural arteriovenous fistulas were also reconstructed after bone subtraction. Subsequently, colored dot signs were placed at the bifurcation of the segmental artery from T5 to L5. The main feeder to the spinal epidural arteriovenous fistula was the peripheral branch of the left L3 segmental artery (Fig. 2). This dot-marked 3D sCTA imaging data were transferred to a workstation for sDSA (Azurion, Philips). Dot-marked sCTA images were observed on the multiwindow DSA display. The angles of the sCTA images were adjusted along with that of the sDSA. The dot signs of sCTA guided catheter introduction for 18 bifurcations of the right T8–L3 and left T7–L4 segmental arteries. The Adamkiewicz artery, which was not revealed on CTA, was identified with selection of the right T11 segmental artery (Fig. 2 and Video 1). The right L2 and left L2 and L3 segmental arteries were fed into the epidural arteriovenous fistula (Fig. 3). The total dose area product was 355.754 Gy/m2, and the exposure cumulative dose area product was 283.387 Gy/m2. The number of exposure series and images, including rotational DSA of two segmental arteries and a single series of cone-beam CT, were 47 and 1,933, respectively. The total fluoroscopy time was 46 minutes 7 seconds. The fluoroscopy cumulative dose-area product was 72.367 Gy/m2. The total air kerma dose was 1,292 mGy. The volume of contrast material was 190 mL.

VIDEO 1. Clip showing that spinal computed tomography angiography images were used as a guidance during spinal digital subtraction angiography. Click here to view.

FIG. 2.
FIG. 2.

Preoperative preparation using CTA and sDSA images in representative segmental arteries. White arrows indicate the bifurcation of the right T11 segmental artery; white arrowheads, the left L3 segmental artery; black arrow, artery of Adamkiewicz; black arrowhead, epidural arteriovenous fistula. The bifurcation of the segmental arteries from the aorta is marked on axial CTA images (A and B). C: The markers for bifurcations are merged with vascular and spine images. The markers and segmental arteries are shown in different colors. D and E: The pointed bifurcation and structure of the right T11 radicular artery are fused with the vertebral structures. F and G: The feeder and drainer of the spinal epidural arteriovenous fistula were reconstructed and fused, respectively. The same method was applied to all segmental arteries. Fusion and intraprocedural images. H: The sDSA was performed, referring to the fusion image. I–K: The intraprocedural and fusion images were shown on the screen. sDSA shows canulation and angiography of the right T11 segmental artery. The right T11 segmental artery was selected based on the fusion image and the bony structure. The artery of Adamkiewicz branches from the right T11 radicular artery. L–N: sDSA showing canulation and angiography of the left L3 segmental artery. The left L3 segmental artery was selected based on the fusion image. An epidural spinal arteriovenous fistula was also identified. The same method was applied to all segmental arteries.

FIG. 3.
FIG. 3.

The epidural arteriovenous fistula is fed by the right L2 (A) and left L2 (B) and L3 (C) segmental arteries and is drained into the radiculomedullary vein (black arrowheads).

Six days after the sDSA, transarterial embolization of the spinal epidural arteriovenous fistula was performed. As an intraoperative guide, preoperative rotational sDSA images related to the epidural spinal arteriovenous fistula were merged with the dot-marked 3D sCTA. A 5-Fr, 55-cm Flexor Ansel guiding sheath was inserted into the right femoral artery. The left L3 segmental artery was selected using a 4-Fr C2 Cobra catheter (Terumo Clinical Supply Co., Ltd). A TACTICS microcatheter (Technocrat Corporation) was guided to the segmental artery with a 0.025-Fr, 260-cm Radifocus guidewire (Terumo Corporation). A DeFrictor Nano catheter (Medico’s Hirata Inc.) was introduced just before the shunting point through the left L3 dorsal segmental artery using an ASAHI CHIKAI 10 (Asahi Intecc Co., Ltd.). We validated the selection of the dural arteriovenous shunt, and the rotational sDSA image demonstrated no arterial feeding to the spinal cord. The venous pouch was filled with 0.5 mL of 20% n-butyl-2-cyanoacrylate. There were no ischemic, hemorrhagic, or neurological complications associated with the procedure. The sensory disturbances and motor weakness of the lower extremities improved. MRI 3 months after the endovascular surgery revealed resolution of flow voids and spinal cord edema (Fig. 4).

FIG. 4.
FIG. 4.

Postoperative radiological images. A: Sagittal short tau inversion recovery MRI sequence shows that the flow voids resolved and spinal cord edema decreased. B: Sagittal CTA image shows that vascular enhancement on the ventral and dorsal surface of the thoracolumbar spinal cord disappeared.

Discussion

Observations

Thoracolumbar epidural arteriovenous fistulas are fed by bilateral and multiple segmental arteries.1,7,9 Thus, a preoperative detailed vascular anatomical examination is essential to treat complex and difficult arteriovenous fistulas.sDSA is the gold standard for evaluating thoracolumbar epidural arteriovenous fistulas;1,4,7,9 however, thorough examinations of thoracolumbar arteriovenous fistulas using sDSA require individual catheterization of multiple segmental arteries.10 Furthermore, fluoroscopy time, radiation exposure, and amount of contrast agent are often increased.11 Aortography can be helpful in decreasing fluoroscopy time, radiation exposure, and amount of contrast agent because segmental arteries can be detected using aortography.12 However, aortography should be repeated for the upper thoracic lesion and the sacral lesion. Paradoxically, radiation exposure and the amount of contrast agent required can increase consequently. Hypoplasia or arteriosclerosis of the segmental artery and a common bifurcation of the bilateral segmental arteries may not be completely identified on two-dimensional aortography images alone.

The use of sDSA to diagnose a spinal arteriovenous fistula was described in pediatric and adult cases;13–16 thus, combined radiological diagnostic modalities with sDSA, such as CTA, 3D rotational angiography, and magnetic resonance angiography, have been reported (Table 1).4,13–19 Although a possible reduction of radiation exposure in sDSA using an assistant radiological modality preceding sDSA was mentioned in previous reports, they did not describe the detailed information related to radiation exposure in sDSA such as Air Kerma and dose-area product (total, DSA, and fluoro). Only in the report by Guatam et al. was the radiation exposure dosage in pediatric cases described.4,14,17–19

TABLE 1.

Summary of the diagnostic modalities combined with sDSA for spinal arteriovenous fistulae

Authors & YearDiagnostic ModalityNo. of PtsAir Kerma in Gy (range)DAP Total in Gy·cm2 (range)DAP DSA in Gy·cm2 (range)DAP Fluoro in Gy·cm2 (range)
sDSA only 
 Ropper et al., 201213sDSA only29 2.96 ± 1.94 (0.72–6.43)372.7 ± 267.8 (65.9–808.0)NANA
 Gautam et al., 202114sDSA only24 (ped)0.1869 (0.022–0.6098)1188.8 (65.2–9130.6)736.9 (42.5–2118.9)96.5 (9.3–364.9)
 Varghese et al., 201915sDSA only7 1.4 (0.5–2.7)186.7 (44.0–377.5)NANA
 Opitz et al., 20221658 N299.55NANA
MRA assist 
 Saindane et al., 201517CE-TR MRA (+) sDSA6 NANANANA
 Luetmer et al., 200518MRA-localized AVF13 NANANANA
CTA assist 
 Yamaguchi et al., 201019IV CTA + sDSA10 NANANANA
 Yamaguchi et al., 201744D IV CTA + sDSA10 NANANANA
3DRA assist 
 Ropper et al., 201213sDSA + 3DRA8 3.44 ± 2.45 (0.55–6.75)409.5 ± 318.6 (60.9–932.0)NANA
CTA guided 
 Current caseIV CTA + sDSA + 3DRA1 1.292355.754283.38772.367

3DRA = three-dimensional rotational angiography; AVF = arteriovenous fistula; CE-TR = contrast-enhanced time-resolved; DAP = dose-area product; IV = intravenous; MRA = magnetic resonance angiography; NA = not available; ped = pediatric; Pts = patients.

Unlike the techniques mentioned above, we used sCTA images as an intraprocedural guide to effectively and easily detect bifurcations of the segmental arteries. The pre-sDSA requirements are simple: bifurcations of the segmental arteries are marked with different colored dots on the axial images of the sCTA. The dots and vascular bifurcation images are then fused with the translucent spine images of the sCTA images. During sDSA, the bifurcation-dotted sCTA images can be merged from the perspective images of sDSA. A bifurcation-dotted mark on the sCTA artery and spine image can guide catheter introduction into the preferred segmental artery for performing sDSA effectively.

The spinal level of multiple segment arteries is discriminated using different colored dots for easy recognition by the examiners. This simple and novel sCTA-guided sDSA can be beneficial for both patients and physicians. For patients, the accuracy of sCTA guidance can minimize sDSA procedure time, radiation exposure dose, and total amount of contrast agent. Intraarterial aortography can be omitted because merged sCTA images can guide the location of the arterial bifurcation. For physicians, sCTA can reveal the anatomy of the aorta and segmental artery prior to sDSA, such as the pathway of the aorta, location of the segmental artery bifurcations, and stenosis and/or common bifurcation of the segmental arteries. The physician can also examine the anatomical relationship between the dotted bifurcation and spinal architectures, such as pedicles, vertebral bodies, and vertebral endplates, which is useful for accurately canulating a catheter to the bifurcation.

This technical case report is limited to a single case, and it does not involve a group comparison or prospective analysis. The usefulness of this method should be evaluated in future studies. Additionally, because an application that can simultaneously merge sDSA images with bifurcation-dotted sCTA images during sDSA procedure is not available at our institute, we did not evaluate the usefulness of the intraprocedural fusion of the sDSA and bifurcation-dotted sCTA images; that requires further research. It should also be evaluated whether our method of using sCTA images as intraprocedural guide in sDSA can reduce radiation exposure.

In conclusion, three-dimensional sCTA can provide detailed anatomical information before sDSA. Modified sCTA images with segmental artery bifurcation marking can provide interactive guidance on multipanel DSA displays. sCTA-guided sDSA is useful for accurate catheterization and reduction in duration of the procedure.

Lessons

3D sCTA can provide detailed anatomical information prior to sDSA. Modified sCTA images with segmental artery bifurcation marking can be performed through interactive guidance on the multipanel DSA display. sCTA-guided sDSA is useful for accurate catheterization and reduction in duration of the procedure.

Acknowledgments

We would like to thank Editage for English language editing.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Hashikata, Ishibashi. Acquisition of data: Hashikata. Analysis and interpretation of data: Hashikata, Maki. Drafting the article: Maki, Toda. Critically revising the article: Hashikata, Ishibashi, Toda. Reviewed submitted version of manuscript: Hashikata, Toda. Approved the final version of the manuscript on behalf of all authors: Hashikata. Study supervision: Toda.

Supplemental Information

Video

Video 1. https://vimeo.com/739648064.

References

  • 1

    Kiyosue H, Matsumaru Y, Niimi Y, et al. Angiographic and clinical characteristics of thoracolumbar spinal epidural and dural arteriovenous fistulas. Stroke. 2017;48(12):32153222.

    • Crossref
    • PubMed
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    D’Orazio F, Splendiani A, Gallucci M. 320-row detector dynamic 4D-CTA for the assessment of brain and spinal cord vascular shunting malformations: a technical note. Neuroradiol J. 2014;27(6):710717.

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    Doppman JL, Krudy AG, Miller DL, Oldfield E, Di Chiro G. Intraarterial digital subtraction angiography of spinal arteriovenous malformations. AJNR Am J Neuroradiol. 1983;4(5):10811085.

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    Opitz M, Zensen S, Bos D, et al. Radiation exposure in the endovascular therapy of cranial and spinal dural arteriovenous fistula in the last decade: a retrospective, single-center observational study. Neuroradiology. 2022;64(3):587595.

    • Crossref
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    • Search Google Scholar
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    Saindane AM, Boddu SR, Tong FC, Dehkharghani S, Dion JE. Contrast-enhanced time-resolved MRA for pre-angiographic evaluation of suspected spinal dural arterial venous fistulas. J Neurointerv Surg. 2015;7(2):135140.

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    • Search Google Scholar
    • Export Citation
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    Yamaguchi S, Nagayama T, Eguchi K, Takeda M, Arita K, Kurisu K. Accuracy and pitfalls of multidetector-row computed tomography in detecting spinal dural arteriovenous fistulas. J Neurosurg Spine. 2010;12(3):243248.

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  • View in gallery

    Preoperative radiological images. A: Sagittal short tau inversion recovery MRI sequence shows spinal cord edema from the T6 to T12 level. The conus medullaris is also edematous. Multiple flow voids are identified. B: Sagittal CTA image shows vascular enhancement on the ventral and dorsal surface of the thoracolumbar spinal cord.

  • View in gallery

    Preoperative preparation using CTA and sDSA images in representative segmental arteries. White arrows indicate the bifurcation of the right T11 segmental artery; white arrowheads, the left L3 segmental artery; black arrow, artery of Adamkiewicz; black arrowhead, epidural arteriovenous fistula. The bifurcation of the segmental arteries from the aorta is marked on axial CTA images (A and B). C: The markers for bifurcations are merged with vascular and spine images. The markers and segmental arteries are shown in different colors. D and E: The pointed bifurcation and structure of the right T11 radicular artery are fused with the vertebral structures. F and G: The feeder and drainer of the spinal epidural arteriovenous fistula were reconstructed and fused, respectively. The same method was applied to all segmental arteries. Fusion and intraprocedural images. H: The sDSA was performed, referring to the fusion image. I–K: The intraprocedural and fusion images were shown on the screen. sDSA shows canulation and angiography of the right T11 segmental artery. The right T11 segmental artery was selected based on the fusion image and the bony structure. The artery of Adamkiewicz branches from the right T11 radicular artery. L–N: sDSA showing canulation and angiography of the left L3 segmental artery. The left L3 segmental artery was selected based on the fusion image. An epidural spinal arteriovenous fistula was also identified. The same method was applied to all segmental arteries.

  • View in gallery

    The epidural arteriovenous fistula is fed by the right L2 (A) and left L2 (B) and L3 (C) segmental arteries and is drained into the radiculomedullary vein (black arrowheads).

  • View in gallery

    Postoperative radiological images. A: Sagittal short tau inversion recovery MRI sequence shows that the flow voids resolved and spinal cord edema decreased. B: Sagittal CTA image shows that vascular enhancement on the ventral and dorsal surface of the thoracolumbar spinal cord disappeared.

  • 1

    Kiyosue H, Matsumaru Y, Niimi Y, et al. Angiographic and clinical characteristics of thoracolumbar spinal epidural and dural arteriovenous fistulas. Stroke. 2017;48(12):32153222.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    D’Orazio F, Splendiani A, Gallucci M. 320-row detector dynamic 4D-CTA for the assessment of brain and spinal cord vascular shunting malformations: a technical note. Neuroradiol J. 2014;27(6):710717.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Mull M, Othman A, Dafotakis M, Hans FJ, Schubert GA, Jablawi F. Spinal epidural arteriovenous fistula with perimedullary venous reflux: clinical and neuroradiologic features of an underestimated vascular disorder. AJNR Am J Neuroradiol. 2018;39(11):20952102.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Yamaguchi S, Takemoto K, Takeda M, et al. The position and role of four-dimensional computed tomography angiography in the diagnosis and treatment of spinal arteriovenous fistulas. World Neurosurg. 2017;103:611619.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Zhou G, Li MH, Lu C, et al. Dynamic contrast-enhanced magnetic resonance angiography for the localization of spinal dural arteriovenous fistulas at 3T. J Neuroradiol. 2017;44(1):1723.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Brinjikji W, Yin R, Nasr DM, Lanzino G. Spinal epidural arteriovenous fistulas. J Neurointerv Surg. 2016;8(12):13051310.

  • 7

    Chul Suh D, Gon Choi C, Bo Sung K, Kim KK, Chul Rhim S. Spinal osseous epidural arteriovenous fistula with multiple small arterial feeders converging to a round fistular nidus as a target of venous approach. AJNR Am J Neuroradiol. 2004;25(1):6973.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Orrù E, Mekabaty AE, Millan DS, Pearl MS, Gailloud P. Removal of antiscatter grids for spinal digital subtraction angiography: dose reduction without loss of diagnostic value. Radiology. 2020;295(2):390396.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Kiyosue H, Tanoue S, Okahara M, Hori Y, Kashiwagi J, Mori H. Spinal ventral epidural arteriovenous fistulas of the lumbar spine: angioarchitecture and endovascular treatment. Neuroradiology. 2013;55(3):327336.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Santillan A, Nacarino V, Greenberg E, Riina HA, Gobin YP, Patsalides A. Vascular anatomy of the spinal cord. J Neurointerv Surg. 2012;4(1):6774.

  • 11

    Marinello E, Causin F, Brumana MB, Alaibac M. Radiodermatitis after spinal arteriovenous fistula embolisation. BMJ Case Rep. 2016;2016:24.

    • Search Google Scholar
    • Export Citation
  • 12

    Doppman JL, Krudy AG, Miller DL, Oldfield E, Di Chiro G. Intraarterial digital subtraction angiography of spinal arteriovenous malformations. AJNR Am J Neuroradiol. 1983;4(5):10811085.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Ropper AE, Lin N, Gross BA, et al. Rotational angiography for diagnosis and surgical planning in the management of spinal vascular lesions. Neurosurg Focus. 2012;32(5):E6.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Gautam A, Motaghi M, Gailloud P. Safety of diagnostic spinal angiography in children. J Neurointerv Surg. 2021;13(4):390394.

  • 15

    Varghese A, Keshava SN, Moses V, et al. Radiation dose reference card for interventional radiology procedures: experience in a tertiary referral centre. Indian J Radiol Imaging. 2019;29(3):247252.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Opitz M, Zensen S, Bos D, et al. Radiation exposure in the endovascular therapy of cranial and spinal dural arteriovenous fistula in the last decade: a retrospective, single-center observational study. Neuroradiology. 2022;64(3):587595.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Saindane AM, Boddu SR, Tong FC, Dehkharghani S, Dion JE. Contrast-enhanced time-resolved MRA for pre-angiographic evaluation of suspected spinal dural arterial venous fistulas. J Neurointerv Surg. 2015;7(2):135140.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Luetmer PH, Lane JI, Gilbertson JR, Bernstein MA, Huston J 3rd, Atkinson JLD. Preangiographic evaluation of spinal dural arteriovenous fistulas with elliptic centric contrast-enhanced MR angiography and effect on radiation dose and volume of iodinated contrast material. AJNR Am J Neuroradiol. 2005;26(4):711718.

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    Yamaguchi S, Nagayama T, Eguchi K, Takeda M, Arita K, Kurisu K. Accuracy and pitfalls of multidetector-row computed tomography in detecting spinal dural arteriovenous fistulas. J Neurosurg Spine. 2010;12(3):243248.

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