Introduction: We present a retrospective analysis of our recent experience in the diagnosis and treatment of spinal dural arteriovenous fistulae (dAVF). Gadolinium-bolus MRA results are compared to spinal angiography.
Methods: Since 2010, 19 consecutive patients with spinal dAVF were treated at our institution. The demographics, MRI/MRA results, fluoroscopy time and amount of iodinated contrast used during initial angiography, treatment modality, post-operative angiography results, neurological exam at follow-up, and pre- and post-operative modified Rankin Scale (mRS) were analyzed.
Results: Of 19 patients, 16 were male and 3 were female. The average age was 68, range 43-85. The fistula locations were 1 cervical, 9 thoracic, 8 lumbar, and 1 sacral. Initial MRI/MRA correctly localized the dAVF in 7 patients (37%, Group A), localized within 3 levels in 6 patients (32%, Group B), and did not localize the dAVF in 6 patients (32%, Group C). Groups A, B, and C averaged 14.4, 17.3, and 43.2 minutes of fluoroscopy time and used an average of 62, 83, and 180 mL of iodinated contrast, respectively. 18 patients underwent microsurgical ligation; 1 patient underwent embolization intially, but symptomatic recurrence required surgery. 17 of 19 patients had post-operative angiograms: 15 of these demonstrated successful obliteration, 1 was subsequently embolized, and 1 required re-operation. On follow-up examination, 14 patients improved neurologically, 3 were unchanged, 1 was worse, and 1 was lost to follow up. In terms of functional independence as measured by mRS, 4 improved, 13 were stable, and 1 was worse.
Conclusions: Approximating the location of spinal dAVF on MRI/MRA is associated with less fluoroscopy time and iodinated contrast used. Microsurgical ligation of the dAVF had a high obliteration rate, but post-operative angiography is necessary. dAVF obliteration usually resulted in neurological improvement, but mRS was generally not improved, likely secondary to long-standing myelopathy prior to disease recognition.
Patient Care: We are presenting a relatively large and recent case series supporting the use of high quality MRA, surgical intervention, and post operative angiography in the diagnosis and treatment of spinal dural AV fistulae. We hope this will positively impact patients affected by these relatively rare and often late-diagnosed lesions.
Learning Objectives: The audience will learn the importance of obtaining high quality gaolinium-bolus MRA for suspected spinal dural AV fistulae, the high rate of obliteration with microsurgical obliteration, and the importance of obtaining post-operative angiography to confirm lesion obliteration.