Endovascular treatment of intracranial dural arteriovenous fistulas with spinal perimedullary venous drainage

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✓ Intracranial dural arteriovenous (AV) fistulas with spinal perimedullary venous drainage are rare lesions that have distinctive clinical, radiological, and therapeutic aspects. Five patients presented with an ascending myelopathy, which extended to involve the brain stem in three cases. Myelography and magnetic resonance imaging showed slightly dilated spinal perimedullary vessels. Spinal angiograms were normal in the arterial phase. Diagnosis was only possible after cerebral angiography, which demonstrated posterior fossa AV fistulas fed by meningeal arteries and draining into spinal perimedullary veins. Endovascular treatment alone resulted in angiographic obliteration of the lesion in three patients. Two patients required surgery in addition to endovascular therapy. One patient died postoperatively, and in one a transient complication of embolization was observed. Improvement after treatment was good in two cases and fair in two. Transverse sinus thrombosis was observed in three cases and was probably the cause of the aberrant venous drainage of the fistula into the spinal perimedullary veins. The pathophysiology is related to spinal cord venous hypertension. These lesions were classified as Type 5 in the Djindjian and Merland classification of dural intracranial AV fistulas. Endovascular therapy is a safe effective method in the treatment of these fistulas and should be tried first.

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Address reprint requests to: Y. Pierre Gobin, M.D., Service de Neuroradiologie, Hôpital Lariboisière, 2 rue Ambroise Paré, 75745 Paris, France.

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    Case 5. Myelograms of the cervical (left) and lumbar (right) spine showing serpentine subarachnoid filling defects (arrows) at the cervical, dorsal, and lumbar levels.

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    Case 5. Magnetic resonance images in the sagittal plane, short spin-echo sequence, showing a slight serpentine signal-void area in the spinal perimedullary region (arrows).

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    Left external carotid artery angiograms in Case 5. Left: Angiogram demonstrating a dural arteriovenous fistula supplied by the petrosal branches of the middle meningeal artery (large arrowhead) and the posterior branch of the middle meningeal artery (small arrowhead). The fistula is located on the superior petrosal sinus (black arrow) and drains into the anterior spinal cervical vein (open arrow) through the perimesencephalic veins. Center: Angiogram, lateral cervical view, late phase, demonstrating the cervical anterior (open arrow) and posterior (black arrow) perimedullary venous drainage. Right: Angiogram, frontal view, venous phase, showing no filling of the left transverse sinus.

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    Case 5. Angiogram showing selective catheterization of the petrosal branch of the middle meningeal artery (arrowheads) feeding the superior petrosal sinus (arrow). The dotted line represents the microcatheter.

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    Case 5. Left: Standard x-ray film obtained after embolization. Note the cast of the N-butyl cyanoacrylate glue after embolization of the superior petrosal sinus (arrowhead). A follow-up angiogram performed after embolization (not shown) revealed complete closure of the fistula. Right: Spinal cord angiogram, right lumbar artery injection at L-1, showing the venous phase of the artery of Adamkiewicz at 13 seconds. The spinal cord venous drainage is now visualized after a normal delay (arrow). Before embolization, the draining veins were not seen.

References

  • 1.

    Awad IALittle JRAkrawi WPet al: Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:8398501990Awad IA Little JR Akrawi WP et al: Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course. J Neurosurg 72:839–850 1990

    • Search Google Scholar
    • Export Citation
  • 2.

    Barnwell SLHalbach VVDowd CFet al: Multiple dural arteriovenous fistulas of the cranium and spine. AJNR 12:4414451991Barnwell SL Halbach VV Dowd CF et al: Multiple dural arteriovenous fistulas of the cranium and spine. AJNR 12:441–445 1991

    • Search Google Scholar
    • Export Citation
  • 3.

    Castaigne PBories JBrunet Pet al: Les fistules artério-veineuses méningées pures à drainage veineux cortical. Rev Neurol 132:1691821976Castaigne P Bories J Brunet P et al: Les fistules artério-veineuses méningées pures à drainage veineux cortical. Rev Neurol 132:169–182 1976

    • Search Google Scholar
    • Export Citation
  • 4.

    Djindjian RMerland JJ: Superselective Arteriography of the External Carotid Artery. Berlin: Springer-Verlag1978 pp 606628Djindjian R Merland JJ: Superselective Arteriography of the External Carotid Artery. Berlin: Springer-Verlag 1978 pp 606–628

    • Search Google Scholar
    • Export Citation
  • 5.

    Fermand MReizine DMelki JPet al: Long term follow-up of 43 pure dural arteriovenous fistulae (AVF) of the lateral sinus. Neuroradiology 29:3483531987Fermand M Reizine D Melki JP et al: Long term follow-up of 43 pure dural arteriovenous fistulae (AVF) of the lateral sinus. Neuroradiology 29:348–353 1987

    • Search Google Scholar
    • Export Citation
  • 6.

    Gaensler EHJackson DEHalbach VV: Arteriovenous fistulas of the cervicomedullary junction as a cause of myelopathy: radiographic findings in two cases. AJNR 11:5185211990Gaensler EH Jackson DE Halbach VV: Arteriovenous fistulas of the cervicomedullary junction as a cause of myelopathy: radiographic findings in two cases. AJNR 11:518–521 1990

    • Search Google Scholar
    • Export Citation
  • 7.

    Gaston AChiras JBourbotte Get al: Meningeal arteriovenous fistulae draining into cortical veins. 31 cases. J Neuroradiol 11:1611771984Gaston A Chiras J Bourbotte G et al: Meningeal arteriovenous fistulae draining into cortical veins. 31 cases. J Neuroradiol 11:161–177 1984

    • Search Google Scholar
    • Export Citation
  • 8.

    Houser OWBaker HL JrRhoton AL Jret al: Intracranial dural arteriovenous malformations. Radiology 105:55641972Houser OW Baker HL Jr Rhoton AL Jr et al: Intracranial dural arteriovenous malformations. Radiology 105:55–64 1972

    • Search Google Scholar
    • Export Citation
  • 9.

    Lasjaunias PChiu MTerBrugge Ket al: Neurological manifestations of intracranial dural arteriovenous malformations. J Neurosurg 64:7247301986Lasjaunias P Chiu M TerBrugge K et al: Neurological manifestations of intracranial dural arteriovenous malformations. J Neurosurg 64:724–730 1986

    • Search Google Scholar
    • Export Citation
  • 10.

    Launay MChiras JBories J: Angiography of the spinal cord: venous phase. Normal features. Pathological application. J Neuroradiol 6:2873151979Launay M Chiras J Bories J: Angiography of the spinal cord: venous phase. Normal features. Pathological application. J Neuroradiol 6:287–315 1979

    • Search Google Scholar
    • Export Citation
  • 11.

    Merland JJRiché MCChiras J: Intraspinal extramedullary arteriovenous fistulae draining into the medullary veins. J Neuroradiol 7:2713201980Merland JJ Riché MC Chiras J: Intraspinal extramedullary arteriovenous fistulae draining into the medullary veins. J Neuroradiol 7:271–320 1980

    • Search Google Scholar
    • Export Citation
  • 12.

    Newton THCronqvist S: Involvement of the dural arteries in intracranial arteriovenous malformations. Radiology 93:107110781969Newton TH Cronqvist S: Involvement of the dural arteries in intracranial arteriovenous malformations. Radiology 93:1071–1078 1969

    • Search Google Scholar
    • Export Citation
  • 13.

    Picard LBracard SMoret Jet al: Spontaneous dural arteriovenous fistulas. Semin Intervent Radiol 4:2192411987Picard L Bracard S Moret J et al: Spontaneous dural arteriovenous fistulas. Semin Intervent Radiol 4:219–241 1987

    • Search Google Scholar
    • Export Citation
  • 14.

    Piton JGuilleux MHGuibert-Tranier Fet al: Fistulae of the lateral sinus. J Neuroradiol 11:1431591984Piton J Guilleux MH Guibert-Tranier F et al: Fistulae of the lateral sinus. J Neuroradiol 11:143–159 1984

    • Search Google Scholar
    • Export Citation
  • 15.

    Rivierez MGazengel JChiras Jet al: Les fistules artério-veineuses vertébro-durales du trou occipital à drainage médullaire. Deux observations. Neurochirurgie 37:1791841991Rivierez M Gazengel J Chiras J et al: Les fistules artério-veineuses vertébro-durales du trou occipital à drainage médullaire. Deux observations. Neurochirurgie 37:179–184 1991

    • Search Google Scholar
    • Export Citation
  • 16.

    Symon LKuyama HKendall B: Dural arteriovenous malformations of the spine. Clinical features and surgical results in 55 cases. J Neurosurg 60:2382471984Symon L Kuyama H Kendall B: Dural arteriovenous malformations of the spine. Clinical features and surgical results in 55 cases. J Neurosurg 60:238–247 1984

    • Search Google Scholar
    • Export Citation
  • 17.

    Viñuela FFox AJPelz DMet al: Unusual clinical manifestations of dural arteriovenous malformations. J Neurosurg 64:5545581986Viñuela F Fox AJ Pelz DM et al: Unusual clinical manifestations of dural arteriovenous malformations. J Neurosurg 64:554–558 1986

    • Search Google Scholar
    • Export Citation
  • 18.

    Willinsky RLasjaunias PTerbrugge Ket al: Angiography in the investigation of spinal dural arteriovenous fistula. A protocol with application of the venous phase. Neuroradiology 32:1141161990Willinsky R Lasjaunias P Terbrugge K et al: Angiography in the investigation of spinal dural arteriovenous fistula. A protocol with application of the venous phase. Neuroradiology 32:114–116 1990

    • Search Google Scholar
    • Export Citation
  • 19.

    Woimant FMerland JJRiché MCet al: Syndrome bulbo-médullaire en rapport avec une fistule artério-veineuse méningée du sinus latéral à drainage veineux médullaire. Rev Neurol 138:5595661982Woimant F Merland JJ Riché MC et al: Syndrome bulbo-médullaire en rapport avec une fistule artério-veineuse méningée du sinus latéral à drainage veineux médullaire. Rev Neurol 138:559–566 1982

    • Search Google Scholar
    • Export Citation
  • 20.

    Wrobel CJOldfield EHDi Chiro Get al: Myelopathy due to intracranial dural arteriovenous fistulas draining intrathecally into spinal medullary veins. Report of three cases. J Neurosurg 69:9349391988Wrobel CJ Oldfield EH Di Chiro G et al: Myelopathy due to intracranial dural arteriovenous fistulas draining intrathecally into spinal medullary veins. Report of three cases. J Neurosurg 69:934–939 1988

    • Search Google Scholar
    • Export Citation

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