Spinal extradural arteriovenous fistulas

Clinical article

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Object

Our understanding of spinal extradural arteriovenous fistulas (eAVFs) is relatively limited. In this study the authors aimed to provide the demographics, natural history, and treatment results of these rare lesions.

Methods

The authors performed a pooled analysis of data in the PubMed database through December 2012. Individualized patient data were extracted to elucidate demographic, clinical, and angioarchitectural features of spinal eAVFs as well as outcomes following different treatment strategies.

Results

Information on 101 patients was extracted from 63 eligible studies. The mean patient age was 45.9 years, and there was no significant overall sex predilection. Only 3% of the lesions were incidental, whereas 10% occurred in patients who had presented with hemorrhage. None of the 64 patients with at least 1 month of untreated follow-up sustained a hemorrhage over a total of 83.8 patient-years. Patients with lumbosacral eAVFs were significantly older (mean age 58.7 years, p < 0.0001), were significantly more often male (70% male, p = 0.02), had significantly worse presenting Aminoff-Logue motor and bladder scores (p = 0.0008 and < 0.0001, respectively), and had the greatest prevalence of lesions with intradural venous drainage (62% of cases, p < 0.0001). Neurofibromatosis Type 1 (30% of cases, p < 0.0001) and subarachnoid hemorrhage (9% of cases, p = 0.06) were associated with and exclusively found in patients with cervical eAVFs. The overall complete obliteration rate was 91%. After a mean follow-up of 1.7 years, the clinical condition was improved in 89% of patients, the same in 9%, and worse in 2%. Obliteration rates and outcome at follow-up did not significantly differ between surgical and endovascular treatment modalities.

Conclusions

Spinal eAVFs are rare lesions with a low risk of hemorrhage; they cause neurological morbidity as a result of mass effect and/or venous hypertension. Their treatment is associated with a high rate of complete obliteration and improvement in preoperative symptoms.

Abbreviations used in this paper:AL = Aminoff-Logue; AVM = arteriovenous malformation; eAVF = extradural arteriovenous fistula; NF1 = neurofibromatosis Type 1; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Rose Du, M.D., Ph.D., Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St., Boston, MA 02115. email: rdu@partners.org.

Please include this information when citing this paper: published online September 13, 2013; DOI: 10.3171/2013.8.SPINE13186.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Spinal eAVF with intradural venous drainage. Sagittal T2-weighted MR image (A) demonstrating spinal cord edema (arrow). Digital subtraction angiogram (B), anteroposterior view, showing an eAVF supplied by a radicular branch with both paraspinal (diamond) and intradural (arrow) venous drainage; star denotes epidural component. Sagittal (C) and axial (D) reconstructed images from 3D rotational angiography illustrating the epidural component of the fistula (star).

References

  • 1

    Afshar JKDoppman JLOldfield EH: Surgical interruption of intradural draining vein as curative treatment of spinal dural arteriovenous fistulas. J Neurosurg 82:1962001995

  • 2

    Aminoff MJLogue V: The prognosis of patients with spinal vascular malformations. Brain 97:2112181974

  • 3

    Arnaud OBille FPouget JSerratrice GSalamon G: Epidural arteriovenous fistula with perimedullary venous drainage: case report. Neuroradiology 36:4904911994

  • 4

    Asai JHayashi TFujimoto TSuzuki R: Exclusively epidural arteriovenous fistula in the cervical spine with spinal cord symptoms: case report. Neurosurgery 48:137213762001

  • 5

    Bergquist EBergström KHugosson RJorulf H: Complicated arteriovenous fistula after vertebral angiography. Neuroradiology 2:1701751971

  • 6

    Cahan LDHigashida RTHalbach VVHieshima GB: Variants of radiculomeningeal vascular malformations of the spine. J Neurosurg 66:3333371987. (Erratum in J Neurosurg 67: 474 1987)

  • 7

    Chen CJHuang CCHsu YYHsu WC: Small isolated paraspinal arteriovenous fistula. AJNR Am J Neuroradiol 18:3593611997

  • 8

    Cho JHAhn JYKuh SUChin DKYoon YS: Acquired spinal extradural arteriovenous fistula after instrumented lumbar surgery. Case illustration. J Neurosurg Spine 9:832008

  • 9

    Chuang NAShroff MMWillinsky RADrake JMDirks PBArmstrong DC: Slow-flow spinal epidural AVF with venous ectasias: two pediatric case reports. AJNR Am J Neuroradiol 24:190119052003

  • 10

    Clarke MJPatrick TAWhite JBCloft HJKrauss WELindell EP: Spinal extradural arteriovenous malformations with parenchymal drainage: venous drainage variability and implications in clinical manifestations. Neurosurg Focus 26:1E52009

  • 11

    Cluzel PPierot LLeung AGaston AKieffer EChiras J: Vertebral arteriovenous fistulae in neurofibromatosis: report of two cases and review of the literature. Neuroradiology 36:3213251994

  • 12

    Cognard CSemaan HBakchine SMiaux YThibault SSola Martinez MT: Paraspinal arteriovenous fistula with perimedullary venous drainage. AJNR Am J Neuroradiol 16:204420481995

  • 13

    Cosgrove GRThéron J: Vertebral arteriovenous fistula following anterior cervical spine surgery. Report of two cases. J Neurosurg 66:2972991987

  • 14

    Dabus GNimmagadda ARussell EJ: Cervical epidural arteriovenous fistula presenting with radiculopathy: transvenous embolization using Onyx. Interv Neuroradiol 17:3803852011

  • 15

    De Keukeleire KDefreyne LVanlangenhove PVermassen F: Asymptomatic congenital extradural vertebral arteriovenous fistula: treatment with electrolytically detachable coils. Cardiovasc Intervent Radiol 29:3113142006

  • 16

    Deans WRBloch SLeibrock LBerman BMSkultety FM: Arteriovenous fistula in patients with neurofibromatosis. Radiology 144:1031071982

  • 17

    Debrun GLegre JKasbarian MTapias PLCaron JP: Endovascular occlusion of vertebral fistulae by detachable balloons with conservation of the vertebral blood flow. Radiology 130:1411471979

  • 18

    Di Chiro GDoppman JOmmaya AK: Selective arteriography of arteriovenous aneurysms of spinal cord. Radiology 88:106510771967

  • 19

    Fukao SHashimoto NKazekawa KKaku Y: Percutaneous transvenous embolisation of iatrogenic vertebral arteriovenous fistula. Neuroradiology 37:4004021995

  • 20

    Gjertsen ONakstad PHPedersen HDahlberg D: Percutaneous intravertebral body embolization of a traumatic spinal epidural arteriovenous fistula with secondary perimedullary venous reflux. A case report. Interv Neuroradiol 16:971022010

  • 21

    Goyal MWillinsky RMontanera WterBrugge K: Paravertebral arteriovenous malformations with epidural drainage: clinical spectrum, imaging features, and results of treatment. AJNR Am J Neuroradiol 20:7497551999

  • 22

    Gross BADu R: Spinal glomus (type II) arteriovenous malformations: a pooled analysis of hemorrhage risk and results of intervention. Neurosurgery 72:25322013

  • 23

    Guglielmi GViñuela FDuckwiler GDion JStocker A: High-flow, small-hole arteriovenous fistulas: treatment with electro-detachable coils. AJNR Am J Neuroradiol 16:3253281995

  • 24

    Hauck EFNauta HJ: Spontaneous spinal epidural arteriovenous fistulae in neurofibromatosis type-1. Surg Neurol 66:2152212006

  • 25

    Hemphill JC IIISmith WSHalbach VV: Neurologic manifestations of spinal epidural arteriovenous malformations. Neurology 50:8178191998

  • 26

    Heros RCDebrun GMOjemann RGLasjaunias PLNaessens PJ: Direct spinal arteriovenous fistula: a new type of spinal AVM. Case report. J Neurosurg 64:1341391986

  • 27

    Hoffman HBBagan M: Cervical epidural arteriovenous malformation occurring with a spinal neurofibroma. Case report. J Neurosurg 26:3463511967

  • 28

    Hui FTrosselo MPMeisel HJAlvarez HSequeira ELasjaunias P: Paraspinal arteriovenous shunts in children. Neuroradiology 36:69731994

  • 29

    Inci SBertan VCila A: Angiographically occult epidural arteriovenous fistula of the craniocervical junction. Surg Neurol 57:1671732002

  • 30

    Johnson CERussell EJHuckman MS: Resolution of spinal epidural vascular pseudotumor following balloon occlusion of a postoperative vertebral arteriovenous fistula. Neuroradiology 31:5295321990

  • 31

    Kähärä VLehto URyymin PHelén P: Vertebral epidural arteriovenous fistula and radicular pain in neurofibromatosis type I. Acta Neurochir (Wien) 144:4934962002

  • 32

    Kähärä VLehto USajanti J: Presacral arteriovenous fistula: case report. Neurosurgery 53:7747772003

  • 33

    Kawabori MHida KYano SAsano TIwasaki Y: Cervical epidural arteriovenous fistula with radiculopathy mimicking cervical spondylosis. Neurol Med Chir (Tokyo) 49:1081132009

  • 34

    Kendall BEHoare R: Percutaneous transvenous balloon occlusion of arteriovenous fistula. Neuroradiology 20:2032051980

  • 35

    Khaldi AHacein-Bey LOrigitano TC: Spinal epidural arteriovenous fistula with late onset perimedullary venous hypertension after lumbar surgery: case report and discussion of the pathophysiology. Spine (Phila Pa 1976) 34:E775E7792009

  • 36

    Kim LJSpetzler RF: Classification and surgical management of spinal arteriovenous lesions: arteriovenous fistulae and arteriovenous malformations. Neurosurgery 59:5 Suppl 3S195S2012006

  • 37

    Kinoshita MAsai AKomeda SYoshimura KTakeda JUesaka T: Spontaneous regression of a spinal extradural arteriovenous fistula after delivery by cesarean section. Neurol Med Chir (Tokyo) 49:3133152009

  • 38

    Kohno MTakahashi HIde KIshijima BYamada KNemoto S: A cervical dural arteriovenous fistula in a patient presenting with radiculopathy. Case report. J Neurosurg 84:1191231996

  • 39

    Krings TMull MBostroem AOtto JHans FJThron A: Spinal epidural arteriovenous fistula with perimedullary drainage. Case report and pathomechanical considerations. J Neurosurg Spine 5:3533582006

  • 40

    Lannum SStratton J: Spontaneous epidural hematoma of the thoracic spine in a 17-year-old adolescent boy: a case report. Am J Emerg Med 27:628.e5628.e62009

  • 41

    Lim SMChoi IS: Spinal epidural arteriovenous fistula: a unique pathway into the perimedullary vein. A case report. Interv Neuroradiol 15:4664692009

  • 42

    Maheshwari SKale HADesai SBKohli A: Magnetic resonance imaging findings in an unusual case of atlanto axial dislocation and vertebral artery-vein fistulas in a patient of neurofibromatosis-1. Australas Radiol 46:3163182002

  • 43

    Meder JFDevaux BMerland JJFrédy D: Spontaneous disappearance of a spinal dural arteriovenous fistula. AJNR Am J Neuroradiol 16:205820621995

  • 44

    Merland JJReizine DRiche MCGeorge BGuimaraens LLaurent A: Endovascular treatment of vertebral arteriovenous fistulas in twenty-two patients. Ann Vasc Surg 1:73781986

  • 45

    Morello FMoro GTibaldo MSiringo GFaggin WFranciosi A: Acute cervical radiculopathy due to vertebral A-V fistula. Ital J Neurol Sci 13:6036051992

  • 46

    Murayama YUsami SAbe THata YGanaha FMassoud TF: Transvenous Doppler guidewire sonographic monitoring during treatment of a complex vertebral arteriovenous fistula associated with neurofibromatosis type 1. Neuroradiology 41:3283331999

  • 47

    Nagashima CIwasaki TKawanuma SSakaguchi AKamisasa ASuzuki K: Traumatic arteriovenous fistula of the vertebral artery with spinal cord symptoms. Case report. J Neurosurg 46:6816871977

  • 48

    Olson RWBaker HL JrSvien HJ: Arteriovenous fistula: a complication of vertebral angiography: report of a case. J Neurosurg 20:73751963

  • 49

    Packer NPCummins BH: Spontaneous epidural haemorrhage: a surgical emergency. Lancet 1:3563581978

  • 50

    Paolini SColonnese CGalasso VMorace RTola SEsposito V: Extradural arteriovenous fistulas involving the vertebral artery in neurofibromatosis Type 1. J Neurosurg Spine 8:1811852008

  • 51

    Patro SNGupta AKArvinda HRJolapara MBSaini J: Combined transarterial and percutaneous coiling of a spontaneous vertebrovertebral fistula associated with neurofibromatosis Type 1. Case report. J Neurosurg 111:37402009

  • 52

    Pirouzmand FWallace MCWillinsky R: Spinal epidural arteriovenous fistula with intramedullary reflux. Case report. J Neurosurg 87:6336351997

  • 53

    Rangel-Castilla LHolman PJKrishna CTrask TWKlucznik RPDiaz OM: Spinal extradural arteriovenous fistulas: a clinical and radiological description of different types and their novel treatment with Onyx. Clinical article. J Neurosurg Spine 15:5415492011

  • 54

    Ropper AEGross BADu R: Surgical treatment of Type I spinal dural arteriovenous fistulas. Neurosurg Focus 32:5E32012

  • 55

    Sadato ASatow TIshii ATakayama MHashimoto N: Large vertebral arteriovenous fistula treated with stent-grafts—case report. Neurol Med Chir (Tokyo) 43:2502542003

  • 56

    Schievink WIPiepgras DG: Cervical vertebral artery aneurysms and arteriovenous fistulae in neurofibromatosis type 1: case reports. Neurosurgery 29:7607651991

  • 57

    Sghirlanzoni AGemma MPareyson DCimino CBoiardi A: Spinal arteriovenous fistula. A possible cause of paraparesis after epidural anaesthesia. Anaesthesia 44:8318331989

  • 58

    Shankar JJterBrugge KKrings T: Spinal epidural arteriovenous fistula with double perimedullary reflux. Can J Neurol Sci 39:2392412012

  • 59

    Siddhartha WChavhan GBShrivastava MLimaye US: Endovascular treatment for bilateral vertebral arteriovenous fistulas in neurofibromatosis 1. Australas Radiol 47:4574612003

  • 60

    Silva N JrJanuel ACTall PCognard C: Spinal epidural arteriovenous fistulas associated with progressive myelopathy. Report of four cases. J Neurosurg Spine 6:5525582007

  • 61

    Spetzler RFDetwiler PWRiina HAPorter RW: Modified classification of spinal cord vascular lesions. J Neurosurg 96:2 Suppl1451562002

  • 62

    Suh DCChoi CGSung KBKim KKRhim SC: 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 25:69732004

  • 63

    Sutton DPratt AE: Vertebral arterio-venous fistula. Clin Radiol 22:2892951971

  • 64

    Szajner MWeill APiotin MMoret J: Endovascular treatment of a cervical paraspinal arteriovenous malformation via arterial and venous approaches. AJNR Am J Neuroradiol 20:109710991999

  • 65

    Takai KTaniguchi M: Comparative analysis of spinal extradural arteriovenous fistulas with or without intradural venous drainage: a systematic literature review. Neurosurg Focus 32:5E82012

  • 66

    Taylor CGHusami YColquhoun IRByrne JV: Direct cervical vertebro-venous fistula with radiculopathy and MRI changes resolving after successful endovascular embolisation: a report of two cases. Neuroradiology 43:111811222001

  • 67

    Tenjin HKimura SSugawa N: Coil embolization of vertebrovertebral arteriovenous fistula: a case report. Surg Neurol 63:80832005

  • 68

    Ushikoshi SGoto KUda KOgata NTakeno Y: Vertebral arteriovenous fistula that developed in the same place as a previous ruptured aneurysm: a case report. Surg Neurol 51:1681731999

  • 69

    Wada KOhtsuka KTerayama KMaruyama MKumaki SMurata S: Neurofibromatosis with spinal paralysis due to arteriovenous fistula. Arch Orthop Trauma Surg 108:3223241989

  • 70

    Wang QSong DChen G: Endovascular treatment of high-flow cervical direct vertebro-vertebral arteriovenous fistula with detachable coils and Onyx liquid embolic agent. Acta Neurochir (Wien) 153:3473522011

  • 71

    Willinsky RTerBrugge KLasjaunias PMontanera W: The variable presentations of craniocervical and cervical dural arteriovenous malformations. Surg Neurol 34:1181231990

  • 72

    Yoshida SNakazawa KOda Y: Spontaneous vertebral arteriovenous fistula—case report. Neurol Med Chir (Tokyo) 40:2112152000

  • 73

    Zhang HHe MMao B: Thoracic spine extradural arteriovenous fistula: case report and review of the literature. Surg Neurol 66:Suppl 1S18S242006

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