Spinal arteriovenous malformations: a comparison of dural arteriovenous fistulas and intradural AVM's in 81 patients

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✓ The medical records and arteriograms of 81 patients with spinal arteriovenous malformations (AVM's) were reviewed, and the vascular lesions were classified as dural arteriovenous (AV) fistulas or intradural AVM's. Intradural AVM's were further classified as intramedullary AVM's (juvenile and glomus types) and direct AV fistulas, which were extramedullary or intramedullary in location. Dural AV fistulas were defined as being supplied by a dural artery and draining into spinal veins via an AV shunt in the intervertebral foramen. Intramedullary AVM's were defined as having the AV shunt contained at least partially within the cord or pia and receiving arterial supply by medullary arteries.

Of the 81 patients, 27 (33%) had dural AV fistulas and 54 (67%) had intradural AVM's. Several dissimilarities in clinical and radiographic findings of the two subgroups were evident. The patients with intramedullary AVM's were younger; the age at onset of symptoms averaged 27 years compared to 49 years for dural AV fistulas. The most common initial symptom associated with dural AV fistulas was steadily progressive paresis, whereas hemorrhage was the most common presenting symptom in cases of intramedullary lesions. No patients with dural AV fistulas had subarachnoid hemorrhage. Activity exacerbated symptoms more frequently in patients with dural lesions. Associated vascular anomalies occurred only in cases of intradural AVM's. In 96% of the dural lesions the AV nidus was in the low thoracic or lumbar region; in only 15% did the intercostal or lumbar arteries supplying the AVM also provide a medullary artery which supplied the spinal cord. In contrast, most intradural AVM's (84%) were in the cervical or thoracic segments of the spinal cord and all of them were supplied by medullary arteries. Transit of contrast medium through the intradural AVM's was rapid in 80% of cases, suggesting high-flow lesions. Forty-four percent of the patients with AVM's of the spinal cord had associated saccular arterial or venous spinal aneurysms. No dural AV fistulas displayed these characteristics. A good outcome occurred in 88% of patients with dural AV fistulas after nidus obliteration, while 49% of patients with intramedullary AVM's did well after surgery or embolization.

These findings suggest that dural and intradural AVM's differ in etiology (acquired vs. congenital) and that they have different pathophysiology, radiographic findings, clinical presentation, and response to treatment.

Article Information

Address reprint requests to: Edward H. Oldfield, M.D., National Institutes of Health, Surgical Neurology Branch, NINCDS, 9000 Rockville Pike, 10-5N37, Bethesda, Maryland 20892.

© AANS, except where prohibited by US copyright law.

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    Artist's drawing of a normal spinal segment. At each level the spinal ramus of the intercostal or lumbar artery divides into the radicular arteries (which supply the nerve roots) and the dural arteries (which supply the root sleeve and spinal dura). At some levels the intercostal or lumbar artery also gives origin to a medullary artery, which joins the anterior or posterolateral spinal artery to supply the cord. The cord is drained by radial veins to the coronal venous plexus and longitudinal spinal veins on the cord surface. The venous blood passes from the subarachnoid space via medullary veins (arrow), which penetrate the dura adjacent to but separate from the penetration of the nerve roots.

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    Artist's drawing of a dural arteriovenous fistula. The vascular nidus, supplied by the dural artery, is in the dural covering of the nerve root and adjacent spinal dura. The fistula is drained intradurally by retrograde flow (arrow) through the medullary vein and causes engorgement of the coronal venous plexus and the intraparenchymal radial veins.

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    Artist's drawing of a glomus-type intradural arteriovenous malformation. A localized and tightly packed intraparenchymal nidus receives its supply from a single medullary artery and is drained by normal venous routes (arrow).

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    Artist's drawing of a juvenile-type intradural arteriovenous malformation (AVM). An abnormal tangle of vessels fills the spinal cord at involved levels and contains neural parenchyma within the nidus of the AVM. Multiple medullary arteries supply the AVM. Arrow indicates the drainage route.

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    Artist's drawing of an intradural arteriovenous fistula. A medullary artery on the pial surface communicates directly with a pial vein. There is no intervening nidus of abnormal vessels between the feeding artery and the draining vein. Arrow indicates the drainage route.

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    Onset of symptoms in patients with intramedullary arteriovenous malformations (AVM's) was usually in childhood and early adulthood. Dural AVM's presented predominantly in and after middle age.

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    The location of the vascular nidus of intradural arteriovenous malformations (AVM's) was more uniformly distributed along the spinal axis than was the nidus of dural AVM's. The latter showed a predilection for the low thoracic and lumbar regions.

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