Neurosurgical versus endovascular treatment of spinal dural arteriovenous fistulas: a multicenter study of 195 patients

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  • 1 Department of Neurosurgery, Hokkaido University Hospital, Sapporo;
  • 2 Department of Neurosurgery, Kohnan Hospital, Sendai;
  • 3 Department of Orthopaedic Surgery, Niigata University Medical and Dental Hospital, Niigata;
  • 4 Department of Neurosurgery, Dokkyo Medical University Hospital, Tochigi;
  • 5 Department of Neurosurgery, Gunma University Hospital, Gunma;
  • 6 Department of Orthopaedic Surgery, Japanese Red Cross Narita Hospital, Chiba;
  • 7 Department of Neurosurgery, The University of Tokyo Hospital, Tokyo;
  • 8 Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo;
  • 9 Department of Neurosurgery, Yokohama City University Hospital, Yokohama;
  • 10 Department of Neurosurgery, Nagoya University Hospital, Nagoya;
  • 11 Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka;
  • 12 Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka;
  • 13 Department of Neurosurgery, Okayama University Graduate School of Medicine, Okayama;
  • 14 Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, Hiroshima;
  • 15 Department of Neurosurgery, Hiroshima University Hospital, Hiroshima;
  • 16 Department of Neurosurgery, Ehime University Hospital, Ehime;
  • 17 Department of Neurosurgery, Kurume University Hospital, Fukuoka; and
  • 18 Department of Neurosurgery, Kagoshima University Hospital, Kagoshima, Japan
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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.

ABBREVIATIONS AL = Aminoff-Logue; AV = arteriovenous; dAVF = dural AV fistula; ICG = indocyanine green; mRS = modified Rankin Scale; NBCA = N-butyl-cyanoacrylate.

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Contributor Notes

Correspondence Keisuke Takai: Tokyo Metropolitan Neurological Hospital, Tokyo, Japan. takai-nsu@umin.ac.jp.

INCLUDE WHEN CITING Published online November 13, 2020; DOI: 10.3171/2020.6.SPINE20309.

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

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