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Tatsuya Ohtonari, Shinzo Ota, Nobuharu Nishihara, Taisei Ota, Yasue Tanaka, Yoshinobu Sekihara, and Akio Tanaka

Object

An epidural blood patch (EBP) is a widely accepted standard procedure to treat CSF hypovolemia, especially when the epidural CSF leak is detected by spinal MRI or CT myelography (CTM). In quite a few cases, however, the leaked CSF is spread over a large area along the spinal epidural space, making it difficult for the surgeon to clearly identify the true leakage points. In such cases, autologous blood can be infused at multiple spinal levels with multiple entries. In this paper, the authors have devised a new multiple-site EBP method with a single lumbar entry point by way of using an intravenous catheter as a slidable device for continuous infusion. In this report, they introduce this new, single-entry, continuous multiple-site EBP administration technique and report some of the results that they have obtained.

Methods

An EBP was applied via an epidural catheter in 5 patients with spontaneous CSF hypovolemia (3 men and 2 women; mean age 47.2 years, range 34–65 years). The detection of an epidural CSF leak was based on MRI and/or CTM findings. In all cases, however, the leakage sites could not be identified clearly. The main symptoms of these patients were recurrent spontaneous chronic subdural hematoma with orthostatic headache (3 patients) and orthostatic headache only (2 patients). All patients underwent surgery in the prone position on an angiography table, and biplane fluoroscopy was used for accurate manipulation. After administration of a local anesthetic, the authors inserted a 4-Fr short sheath (which is standard in angiography) through the lumbar interlaminar window and placed it in the dorsal epidural space. They then introduced a 4.2-Fr straight catheter through the sheath and navigated it upward along a 35-gauge guidewire whose tip was moved upward beyond the cranial end of the detected CSF leakage. Blood was obtained from each patient from a previously secured venous entry on the forearm, and it was injected slowly into the epidural catheter. Each time, the authors tried to infuse as much autologous blood as possible into the epidural space, while moving the catheter gradually in the caudal direction in response to the patient's expression of pain.

Results

In all 3 cases of chronic subdural hematoma, its recurrence was prevented. In 1 patient, the orthostatic headache disappeared completely, and it was relieved in the other 4 patients.

Conclusions

An efficient treatment option for CSF hypovolemia is provided by the new application method of EBP with the aid of an intravenous catheter as a slidable device, which enables infusion of a sufficient amount of autologous blood into multiple epidural areas with a single lumbar entry point.

Open access

Keisuke Takai, Toshiki Endo, Takao Yasuhara, Toshitaka Seki, Kei Watanabe, Yuki Tanaka, Ryu Kurokawa, Hideaki Kanaya, Fumiaki Honda, Takashi Itabashi, Osamu Ishikawa, Hidetoshi Murata, Takahiro Tanaka, Yusuke Nishimura, Kaoru Eguchi, Toshihiro Takami, Yusuke Watanabe, Takeo Nishida, Masafumi Hiramatsu, Tatsuya Ohtonari, Satoshi Yamaguchi, Takafumi Mitsuhara, Seishi Matsui, Hisaaki Uchikado, Gohsuke Hattori, Nobutaka Horie, Hitoshi Yamahata, and Makoto Taniguchi

OBJECTIVE

Spinal arteriovenous shunts are rare vascular lesions and are classified into 4 types (types I–IV). Due to rapid advances in neuroimaging, spinal epidural AVFs (edAVFs), which are similar to type I spinal dural AVFs (dAVFs), have recently been increasingly reported. These 2 entities have several important differences that influence the treatment strategy selected. The purposes of the present study were to compare angiographic and clinical differences between edAVFs and dAVFs and to provide treatment strategies for edAVFs based on a multicenter cohort.

METHODS

A total of 280 consecutive patients with thoracic and lumbosacral spinal dural arteriovenous fistulas (dAVFs) and edAVFs with intradural venous drainage were collected from 19 centers. After angiographic and clinical comparisons, the treatment failure rate by procedure, risk factors for treatment failure, and neurological outcomes were statistically analyzed in edAVF cases.

RESULTS

Final diagnoses after an angiographic review included 199 dAVFs and 81 edAVFs. At individual centers, 29 patients (36%) with edAVFs were misdiagnosed with dAVFs. Spinal edAVFs were commonly fed by multiple feeding arteries (54%) shunted into a single or multiple intradural vein(s) (91% and 9%) through a dilated epidural venous plexus. Preoperative modified Rankin Scale (mRS) and Aminoff-Logue gait and micturition grades were worse in patients with edAVFs than in those with dAVFs. Among the microsurgical (n = 42), endovascular (n = 36), and combined (n = 3) treatment groups of edAVFs, the treatment failure rate was significantly higher in the index endovascular treatment group (7.5%, 31%, and 0%, respectively). Endovascular treatment was found to be associated with significantly higher odds of initial treatment failure (OR 5.72, 95% CI 1.45–22.6). In edAVFs, the independent risk factor for treatment failure after microsurgery was the number of intradural draining veins (OR 17.9, 95% CI 1.56–207), while that for treatment failure after the endovascular treatment was the number of feeders (OR 4.11, 95% CI 1.23–13.8). Postoperatively, mRS score and Aminoff-Logue gait and micturition grades significantly improved in edAVFs with a median follow-up of 31 months.

CONCLUSIONS

Spinal epidural AVFs with intradural venous drainage are a distinct entity and may be classified as type V spinal vascular malformations. Based on the largest multicenter cohort, this study showed that primary microsurgery was superior to endovascular treatment for initial treatment success in patients with spinal edAVFs.

Open access

Keisuke Takai, Toshiki Endo, Takao Yasuhara, Toshitaka Seki, Kei Watanabe, Yuki Tanaka, Ryu Kurokawa, Hideaki Kanaya, Fumiaki Honda, Takashi Itabashi, Osamu Ishikawa, Hidetoshi Murata, Takahiro Tanaka, Yusuke Nishimura, Kaoru Eguchi, Toshihiro Takami, Yusuke Watanabe, Takeo Nishida, Masafumi Hiramatsu, Tatsuya Ohtonari, Satoshi Yamaguchi, Takafumi Mitsuhara, Seishi Matsui, Hisaaki Uchikado, Gohsuke Hattori, Hitoshi Yamahata, and Makoto Taniguchi

OBJECTIVE

The 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).

METHODS

Data 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.

RESULTS

Spinal 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).

CONCLUSIONS

Based 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.