Three-dimensional angioarchitecture of spinal dural arteriovenous fistulas, with special reference to the intradural retrograde venous drainage system

Clinical article

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Object

There have been significant advances in understanding the angioarchitecture of spinal dural arteriovenous fistulas (AVFs). However, the major intradural retrograde venous drainage system has not been investigated in detail, including the most proximal sites of intradural radiculomedullary veins as they connect to the dura mater, which are the final targets of interruption in both microsurgical and endovascular treatments.

Methods

Between April 1984 and March 2011, 27 patients with 28 AVFs were treated for spinal dural AVFs at the authors' university hospital. The authors assessed vertebral levels of feeding arteries and dural AVFs by using conventional digital subtraction angiography. They also assessed 3D locations of the most proximal sites of intradural radiculomedullary veins and the 3D positional relationship between the major intradural retrograde venous drainage system and intradural neural structures, including the spinal cord, spinal nerves, and the artery of Adamkiewicz, by using operative video recordings plus 3D rotational angiography and/or 3D computer graphics. In addition, they statistically assessed the clinical results of 27 cases. Of these lesions, 23 were treated with open microsurgery and the rest were treated with endovascular methods.

Results

Feeding arteries consisted of T2–10 intercostal arteries with 19 lesions, T-12 subcostal arteries with 3 lesions, and L1–3 lumbar arteries with 6 lesions. The 3D locations of the targets of interruption (the most proximal sites of intradural radiculomedullary veins as they connect to the dura mater) were identified at the dorsolateral portion of the dura mater adjacent to dorsal roots in all 19 thoracic lesions, whereas they were identified at the ventrolateral portion of the dura mater adjacent to ventral roots in 7 (78%) of 9 cases of conus medullaris/lumbar lesions (p < 0.001). The major intradural retrograde venous drainage system was located dorsal to the spinal cord in all 19 thoracic lesions, whereas it was located ventral to the spinal cord in 4 (44%) of 9 cases of conus/lumbar lesions (p = 0.006). In 3 (11%) of 27 cases, AVFs had a common origin of the artery of Adamkiewicz. In 2 lumbar lesions, the artery of Adamkiewicz ascended very close to the vein because of its ventral location. Although all lesions were successfully obliterated without major complications and both gait and micturition status significantly improved (p = 0.005 and p = 0.015, respectively), conus/lumbar lesions needed careful differential diagnosis from ventral intradural perimedullary AVFs, because the ventral location of these lesions contradicted the Spetzler classification system.

Conclusions

The angioarchitecture of spinal dural AVFs in the thoracic region is strikingly different from that in conus/lumbar regions with regard to the intradural retrograde venous drainage system. One should keep in mind that spinal dural AVFs are not always dorsal types, especially in conus/lumbar regions.

Abbreviations used in this paper:AVF = arteriovenous fistula; CG = computer graphics; DSA = digital subtraction angiography; RA = rotational angiography.

Article Information

Address correspondence to: Keisuke Takai, M.D., Ph.D., Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. email: takai-nsu@umin.ac.jp.

Please include this information when citing this paper: published online February 22, 2013; DOI: 10.3171/2013.1.SPINE12305.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A and C: Case 18. Three-dimensional CG images of T-10 thoracic AVF showing the most proximal site of the intradural radiculomedullary vein located at the dorsolateral portion of the dura mater (arrow) and the major intradural retrograde venous drainage system located dorsal to the spinal cord (arrowheads). B and D: Case 27. Three-dimensional CG images of L-3 lumbar AVF showing the most proximal site of the intradural radiculomedullary vein located at the ventrolateral portion of the dura mater (arrow) and the major intradural retrograde venous drainage system located ventral to the spinal cord and cauda equina (arrowheads). Feeding artery (red), draining vein (purple), dura mater (green), spinal cord (yellow), and bone (translucent).

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    A: Case 4. A DS angiogram of the T-6 intercostal artery showing the descending intradural spinal cord vein. The most proximal portion of the radiculomedullary vein as it connects to the dura mater (arrow) is at the same level as the feeding artery. B: Case 17. A DS angiogram of the T-8 intercostal artery showing the ascending dural collateral vessel between T-8 and T-7 (arrowheads). Note a discrepancy between the proximal site of the radiculomedullary vein as it connects to the dura mater (arrow) and the feeding artery. C: Case 22. A DS angiogram of the L-1 lumbar artery showing the ascending radiculomedullary vein draining into the spinal cord vein. The most proximal portion of the radiculomedullary vein as it connects to the dura mater (arrow) is at the same level as the feeding arteries. D: Case 21. A DS angiogram of the T-12 subcostal artery showing the descending dural collateral vessel between T-12 and L-1 (arrowheads). Note a discrepancy between the proximal site of the radiculomedullary vein as it connects to the dura mater (arrow) and the feeding artery.

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    A–C: Two-dimensional lateral DS angiograms showing 3 kinds of flow patterns of the intradural retrograde venous drainage system in conus medullaris/lumbar AVFs. D–F: Case 23. Dural AVF at the lumbar level. A: A DS angiogram of lumbar AVF (L-1) showing the most proximal site of the draining vein located ventral to the cauda equina (black arrow) and the ventral radiculomedullary vein (arrowheads) ascending into ventral spinal cord veins (white arrows). Note that 4 (44%) of 9 cases of conus/lumbar AVFs have this drainage pattern. B: A DS angiogram of lumbar AVF (L-1) showing the most proximal site of the draining vein located ventrally (black arrow) and the ventral radicular vein (arrowheads) ascending into the dorsal spinal cord vein through extrinsic anastomoses (white arrows). Note that 3 (33%) of 9 cases of conus/lumbar AVFs have this drainage pattern. C: A DS angiogram of lumbar AVF (L-2) showing the most proximal site of the draining vein located dorsally (black arrow) and the dorsal radiculomedullary vein (arrowheads) ascending into the dorsal spinal cord vein (white arrows). Note that 2 (22%) of 9 cases of conus/lumbar AVFs have this drainage pattern. D: An intraoperative photograph showing the most proximal site of the intradural radiculomedullary vein (black arrow) located at the ventrolateral portion of the dura mater, ascending adjacent to the ventral roots (white arrowheads). Note that the artery of Adamkiewicz ascends very close to the vein because of its ventral location (black arrowheads). E: Preoperative 2D DS angiogram showing the AVF (black arrow) between the left L-1 lumbar artery and intradural veins, draining into ascending spinal cord veins (white arrowheads). F: Postoperative 2D DS angiogram showing the artery of Adamkiewicz (arrowheads).

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    Graphs showing postoperative changes in Aminoff-Logue gait (upper) and micturition (lower) grades. Both gait and micturition grades significantly improved (p = 0.005, p = 0.015, respectively; Wilcoxon signed-rank test). Each pair of bars represents 1 patient.

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