Recognition of the variant type of spinal dural arteriovenous fistula: a rare but important consideration

Sean T. O’ReillyDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;
Department of Neuroradiology, Royal Victoria Hospital, Belfast, County Antrim, United Kingdom; and

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Eef Jacobus HendriksDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Marie-Christine BrunetDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Ze’ev ItseksonDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Rabab Al ShahraniDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Ronit AgidDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Patrick NicholsonDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Karel terBruggeDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;

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Ivan RadovanovicDepartment of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada

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Timo KringsDivision of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada;
Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada

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OBJECTIVE

Spinal dural arteriovenous fistulas (SDAVFs) typically represent abnormal shunts between a radiculomeningeal artery and radicular vein, with the point of fistulization classically directly underneath the pedicle of the vertebral body, at the dural sleeve of the nerve root. However, SDAVFs can also develop in atypical locations or have more than one arterial feeder, which is a variant of SDAVF. The aim of this study was to describe the incidence and multidisciplinary treatment of variant SDAVFs in a single-center case series.

METHODS

Following institutional review board approval, the authors retrospectively analyzed their prospectively maintained database of patients with SDAVFs who presented between 2008 and 2020. For all patients, spinal digital subtraction angiograms were reviewed and variant SDAVFs were identified. Variant types of SDAVFs were defined as cases in which the fistulous point was not located underneath the pedicle. Patient demographics, angiographic features, clinical outcomes, and treatment modalities were assessed.

RESULTS

Of 59 patients with SDAVFs treated at the authors’ institution, 4 patients (6.8%) were identified as having a variant location of the shunt zone, pinpointed on the dura mater at the intervertebral level, further posteriorly within the spinal canal. In 3 cases (75%), a so-called bimetameric arterial supply was demonstrated.

CONCLUSIONS

Recognition of the variant type of SDAVF is crucial for management, as correct localization of the fistulous point and bimetameric supply are critical for successful surgical disconnection, preventing delay in achieving definitive treatment.

ABBREVIATIONS

DSA = digital subtraction angiography; SDAVF = spinal dural arteriovenous fistula.
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Images from de Andrada Pereira et al. (pp 525–534).

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