Asymptomatic spinal dural arteriovenous fistula: case series and systematic review

Restricted access

OBJECTIVE

Spinal dural arteriovenous fistulas (SDAVFs) commonly present with symptoms of myelopathy due to venous congestion in the spinal cord; asymptomatic SDAVFs are rarely encountered. To elucidate the clinical characteristics of asymptomatic SDAVFs, the authors present 5 new cases of asymptomatic SDAVF and report the results of their systematical review of the associated literature.

METHODS

Five databases were systematically searched for all relevant English-language articles on SDAVFs published from 1990 to 2018. The clinical features and imaging findings of asymptomatic SDAVFs were collected and compared with those of symptomatic SDAVFs.

RESULTS

Twenty cases, including the 5 cases from the authors’ experience, were found. Asymptomatic SDAVFs were more prevalent in the cervical region (35.0%); cervical lesions account for only 2% of all symptomatic SDAVFs. The affected perimedullary veins tended to drain more cranially (50.0%) than caudally (10.0%). Four cases of asymptomatic SDAVF became symptomatic, 1 case spontaneously disappeared, and the remaining 15 cases were unchanged or surgically treated.

CONCLUSIONS

The higher prevalence of asymptomatic SDAVFs in the cervical spine might be a distinct feature of asymptomatic SDAVFs. Given that venous congestion is the pathophysiology of a symptomatic SDAVF, abundant collateral venous pathways and unique flow dynamics of the CSF in the cervical spine might prevent asymptomatic cervical SDAVFs from becoming symptomatic. In cases in which venous congestion is avoidable, not all asymptomatic SDAVFs will become symptomatic.

ABBREVIATIONS CCJ = craniocervical junction; SDAVF = spinal dural arteriovenous fistula.

Article Information

Correspondence Kiyoharu Shimizu: Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan. shimizu.kiyoharu@gmail.com.

INCLUDE WHEN CITING Published online July 19, 2019; DOI: 10.3171/2019.5.SPINE181513.

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

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    PRISMA flowchart for the search strategy in the present systematic review.

  • View in gallery

    Case 1. A: Sagittal T2-weighted MR image demonstrating dilated perimedullary veins on the ventral surface of the cervical spinal cord between C2 and C4. Edema of the spinal cord was not seen. B: Three-dimensional CT angiogram showing an arteriovenous shunt supplied by the left vertebral artery. C: CT scan with contrast medium revealing an SDAVF located within the ventral surface of the dural root sleeve in the left C3–4 intervertebral foramen (arrow). D: Sagittal T2-weighted MR obtained after 6 years of follow-up, showing no apparent changes.

  • View in gallery

    Case 2. A: Sagittal T2-weighted MR image showing dilated perimedullary veins at the dorsal surface of the thoracolumbar spinal cord. Intraspinal edema was not observed. B: Anteroposterior angiograms of the right T5 intercostal artery, revealing shunting of the right T5 radiculomeningeal artery into a radicular vein. C: The SDAVF draining into the left L3 and S2 radiculomedullary vein (arrows). D: A temporary surgical clip was applied to the perimedullary vein immediately distal to the shunting point. E: Indocyanine green video angiogram showing the disconnection of the shunt. F: Postoperative sagittal T2-weighted MR image showing the disappearance of the abnormal flow voids, confirming closure of the shunt.

  • View in gallery

    Case 3. A: Sagittal T2-weighted MR image revealing abnormal flow voids on the dorsal surface of the cervical spinal cord between the craniovertebral junction and C7. Edema within the spinal cord was not identified. B: CT scan with contrast medium identifying an SDAVF at the dural root sleeve in the right C6–7 intervertebral foramen (arrow). C: Anteroposterior angiogram of the right vertebral artery, showing an SDAVF supplied from the right radicular artery at the C6 level. D: Anteroposterior angiogram of the left vertebral artery, revealing the radicular artery at the left C6 supplying the same spinal arteriovenous fistula via the posterior spinal artery.

References

  • 1

    Alhilali LMReynolds ARFakhran S: Value of prominent flow voids without cord edema in the detection of spinal arteriovenous fistulae. PLoS One 9:e990042014

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

    Andres RHBarth AGuzman RRemonda LEl-Koussy MSeiler RW: Endovascular and surgical treatment of spinal dural arteriovenous fistulas. Neuroradiology 50:8698762008

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

    Bakker NAUyttenboogaart MLuijckx GJEshghi OSMazuri AMetzemaekers JD: Recurrence rates after surgical or endovascular treatment of spinal dural arteriovenous fistula: a meta-analysis. Neurosurgery 77:1371442015

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

    Benhaiem NPoirier JHurth M: Arteriovenous fistulae of the meninges draining into the spinal veins. A histological study of 28 cases. Acta Neuropathol 62:1031111983

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

    Clark SPowell GKandasamy JLee MNahser HPigott T: Spinal dural arteriovenous fistulas—presentation, management and outcome in a single neurosurgical institution. Br J Neurosurg 27:4654702013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Do ASKapurch JKumar RPort JMiller JWVan Gompel JJ: The long and winding road: thoracic myelopathy associated with occipitocervical dural arteriovenous fistula. World Neurosurg 108:998.e7998.e162017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Dreha-Kulaczewski SKonopka MJoseph AAKollmeier JMerboldt KDLudwig HC: Respiration and the watershed of spinal CSF flow in humans. Sci Rep 8:55942018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Eckart Sorte DObrzut MWyse EGailloud P: Normal venous phase documented during angiography in patients with spinal vascular malformations: incidence and clinical implications. AJNR Am J Neuroradiol 37:5655712016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Fugate JELanzino GRabinstein AA: Clinical presentation and prognostic factors of spinal dural arteriovenous fistulas: an overview. Neurosurg Focus 32(5):E172012

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

    Fujima NKudo KTerae SHida KIshizaka KZaitsu Y: Spinal arteriovenous malformation: evaluation of change in venous oxygenation with susceptibility-weighted MR imaging after treatment. Radiology 254:8918992010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Gailloud P: The arrow-tipped loop is a marker of radiculomedullary vein thrombosis linked to the anti-reflux mechanism—angiographic anatomy and clinical implications. Neuroradiology 56:8598642014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Gemmete JJChaudhary NElias AEToma AKPandey ASParker RA: Spinal dural arteriovenous fistulas: clinical experience with endovascular treatment as a primary therapy at 2 academic referral centers. AJNR Am J Neuroradiol 34:197419792013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Hassler WThron AGrote EH: Hemodynamics of spinal dural arteriovenous fistulas. An intraoperative study. J Neurosurg 70:3603701989

  • 14

    Hiramatsu MSugiu KIshiguro TKiyosue HSato KTakai K: Angioarchitecture of arteriovenous fistulas at the craniocervical junction: a multicenter cohort study of 54 patients. J Neurosurg 128:183918492018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Houdart ERedondo ASaint-Maurice JPMerland JJ: Natural history of an incidentally discovered spinal dural arteriovenous fistula. Neurology 57:7427432001

  • 16

    Huffmann BCGilsbach JMThron A: Spinal dural arteriovenous fistulas: a plea for neurosurgical treatment. Acta Neurochir (Wien) 135:44511995

  • 17

    Jablawi FSchubert GAHans FJMull M: Anticoagulation therapy after surgical treatment of spinal dural arteriovenous fistula. Effectiveness and long-term outcome analysis. World Neurosurg 114:e698e7052018

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18

    Jellema KTijssen CCvan Gijn J: Spinal dural arteriovenous fistulas: a congestive myelopathy that initially mimics a peripheral nerve disorder. Brain 129:315031642006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kang MSKim KHPark JYKuh SUChin DKJin BH: Comparison of endovascular embolization and surgery in the treatment of spinal intradural dorsal arteriovenous fistulas. World Neurosurg 122:e1519e15272019

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20

    Kiyosue HMatsumaru YNiimi YTakai KIshiguro THiramatsu M: Angiographic and clinical characteristics of thoracolumbar spinal epidural and dural arteriovenous fistulas. Stroke 48:321532222017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Knopman JZink WPatsalides ARiina HAGobin YP: Secondary clinical deterioration after successful embolization of a spinal dural arteriovenous fistula: a plea for prophylactic anticoagulation. Interv Neuroradiol 16:1992032010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Lang MJAtallah ETjoumakaris SRosenwasser RHJabbour P: Remote thoracic myelopathy from a spinal dural arteriovenous fistula at the craniocervical junction: case report and review of literature. World Neurosurg 108:992.e1992.e42017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23

    Mascalchi MScazzeri FProsetti DFerrito GSalvi FQuilici N: Dural arteriovenous fistula at the craniocervical junction with perimedullary venous drainage. AJNR Am J Neuroradiol 17:113711411996

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Matsumoto HMinami HYamaura IYoshida YHirata Y: Newly detected cervical spinal dural arteriovenous fistula on magnetic resonance angiography causing intracranial subarachnoid hemorrhage. World Neurosurg 105:1038.e11038.e92017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

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

  • 26

    Merland JJRiche MCChiras J: Intraspinal extramedullary arteriovenous fistulae draining into the medullary veins. J Neuroradiol 7:2713201980

  • 27

    Moher DLiberati ATetzlaff JAltman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e10000972009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Muralidharan RSaladino ALanzino GAtkinson JLRabinstein AA: The clinical and radiological presentation of spinal dural arteriovenous fistula. Spine (Phila Pa 1976) 36:E1641E16472011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Narvid JHetts SWLarsen DNeuhaus JSingh TPMcSwain H: Spinal dural arteriovenous fistulae: clinical features and long-term results. Neurosurgery 62:1591672008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Ohta TGomi MOowaki HIshikawa M: Chronic venous congestion following embolization of spinal dural arteriovenous fistula. J Neurosurg Spine 9:1861902008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Phan KMobbs RJ: Systematic reviews and meta-analyses in spine surgery, neurosurgery and orthopedics: guidelines for the surgeon scientist. J Spine Surg 1:19272015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Pillai SKSubramaniam TRao GG: Spinal stroke in older people secondary to dural arteriovenous fistula. BMJ Case Rep 2011:bcr06201143732011

  • 33

    Saraf-Lavi EBowen BCQuencer RMSklar EMHolz AFalcone S: Detection of spinal dural arteriovenous fistulae with MR imaging and contrast-enhanced MR angiography: sensitivity, specificity, and prediction of vertebral level. AJNR Am J Neuroradiol 23:8588672002

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Sasamori THida KAsano TOsanai TYano SAoyama T: Transformation from asymptomatic to symptomatic of lower cervical spinal dural arteriovenous fistula. Neurol Med Chir (Tokyo) 53:1031062013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Sato KEndo TNiizuma KFujimura MInoue TShimizu H: Concurrent dural and perimedullary arteriovenous fistulas at the craniocervical junction: case series with special reference to angioarchitecture. J Neurosurg 118:4514592013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Sato KTerbrugge KGKrings T: Asymptomatic spinal dural arteriovenous fistulas: pathomechanical considerations. J Neurosurg Spine 16:4414462012

  • 37

    Shinoyama MEndo TTakahash TShimizu HTakahashi ASuzuki M: Long-term outcome of cervical and thoracolumbar dural arteriovenous fistulas with emphasis on sensory disturbance and neuropathic pain. World Neurosurg 73:4014082010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Stevens EAPowers AKMorris PPWilson JA: Occult dural arteriovenous fistula causing rapidly progressive conus medullaris syndrome and paraplegia after lumbar microdiscectomy. Spine J 9:e8e122009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39

    Stringer MDRestieaux MFisher ALCrosado B: The vertebral venous plexuses: the internal veins are muscular and external veins have valves. Clin Anat 25:6096182012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Toossi SJosephson SAHetts SWChin CTKralik SJun P: Utility of MRI in spinal arteriovenous fistula. Neurology 79:25302012

  • 41

    van Rooij WJNijenhuis RJPeluso JPSluzewski MBeute GNvan der Pol B: Spinal dural fistulas without swelling and edema of the cord as incidental findings. AJNR Am J Neuroradiol 33:188818922012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 42

    Vargas MIDelattre BMABoto JGariani JDhouib AFitsiori A: Advanced magnetic resonance imaging (MRI) techniques of the spine and spinal cord in children and adults. Insights Imaging 9:5495572018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Yamaguchi SEguchi KKiura YTakeda MNagayama TUchida H: Multi-detector-row CT angiography as a preoperative evaluation for spinal arteriovenous fistulae. Neurosurg Rev 30:3213272007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Yamaguchi SNagayama TEguchi KTakeda MArita KKurisu K: Accuracy and pitfalls of multidetector-row computed tomography in detecting spinal dural arteriovenous fistulas. J Neurosurg Spine 12:2432482010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Yamaguchi STakeda MMitsuhara TKajihara SMukada KEguchi K: Application of 4D-CTA using 320-row area detector computed tomography on spinal arteriovenous fistulae: initial experience. Neurosurg Rev 36:2892962013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Yamaguchi STakemoto KTakeda MKajihara YMitsuhara TKolakshyapati M: The position and role of four-dimensional computed tomography angiography in the diagnosis and treatment of spinal arteriovenous fistulas. World Neurosurg 103:6116192017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Yanaka KMatsumaru YUemura KMatsumura AAnno INose T: Perfusion-weighted MRI of spinal dural arteriovenous fistula. Neuroradiology 45:7447472003

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 223 223 156
Full Text Views 108 108 95
PDF Downloads 49 49 41
EPUB Downloads 0 0 0

PubMed

Google Scholar