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A treatment-refractory spinal dural arteriovenous fistula sharing arterial origin with the Artery of Adamkiewicz: Repeated endovascular treatment after failed microsurgery.

Eneling J, Karlsson PM, Rossitti S - Surg Neurol Int (2014)

Bottom Line: Microsurgical disconnection of the SDAVF was attempted, but failed.All procedures were neurologically uncomplicated.The patient presented good, but incomplete neurological improvement.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University Hospital, Linköping, Sweden.

ABSTRACT

Background: Effective management of a spinal dural arteriovenous fistula (SDAVF) can be accomplished with either microsurgery or endovascular embolization, but there is a consensus that in patients in whom a radiculomedullary artery supplying the anterior spinal artery (ASA) originates from the same feeding artery as the SDAVF, the endovascular approach is to be avoided.

Case description: The patient was a 46-year-old woman with progressive lower limb paraparesis, sensory deficit, and sphincter dysfunction. Magnetic resonance imaging (MRI) and spinal angiography showed an SDAVF fed by a branch from the left second lumbar segmental artery, and the artery of Adamkiewicz (AA), a major ASA supplier, originating from the same segmental artery just proximal to the SDAVF. Microsurgical disconnection of the SDAVF was attempted, but failed. Embolization with cyanoacrylates was done in two occasions, the first time through a microcatheter placed just distal to the origin of the AA and the second time through another feeder coming from the same segmental artery that could not be visualized in the previous angiographies. All procedures were neurologically uncomplicated. Magnetic resonance imaging (MRI) 1 month after the last embolization showed resolution of the spinal cord edema. MRI scan taken 68 months after embolization revealed a slightly atrophic spinal cord with visible central canal and no recurrence of medullary edema. The patient presented good, but incomplete neurological improvement.

Conclusion: Microsurgery is the first choice for an SDAVF branching off the same radiculomedullary artery supplying the ASA, but uncomplicated embolization can be feasible after failed surgery.

No MeSH data available.


Related in: MedlinePlus

Digital subtraction angiography (DSA) of the left L2 artery in anterior–posterior projection showing a dural arteriovenous fistula (lower arrow) at the left foramen L2-L3 and the AA (upper arrow: note this artery's vertical course and typical hairpin curve into the descending branch)
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Figure 2: Digital subtraction angiography (DSA) of the left L2 artery in anterior–posterior projection showing a dural arteriovenous fistula (lower arrow) at the left foramen L2-L3 and the AA (upper arrow: note this artery's vertical course and typical hairpin curve into the descending branch)

Mentions: Magnetic resonance imaging (MRI) of the spine showed marked edema and patchy contrast agent enhancement of the spinal cord from the T7 level to the conus medullaris, and enlarged perimedullary veins predominantly on the left side [Figure 1]. Spinal angiography revealed an SDAVF in the left L2-L3 intervertebral foramen, fed by a branch from the second lumbar segmental artery (L2) on the left [Figure 2]. From the very same segmental artery, the artery of Adamkiewicz (AA), a main supplier of the ASA system, branched off about 0.5 cm proximal to the fistula. Due to this anatomical particularity, endovascular embolization of the fistula was considered contraindicated and microsurgical treatment was opted for.


A treatment-refractory spinal dural arteriovenous fistula sharing arterial origin with the Artery of Adamkiewicz: Repeated endovascular treatment after failed microsurgery.

Eneling J, Karlsson PM, Rossitti S - Surg Neurol Int (2014)

Digital subtraction angiography (DSA) of the left L2 artery in anterior–posterior projection showing a dural arteriovenous fistula (lower arrow) at the left foramen L2-L3 and the AA (upper arrow: note this artery's vertical course and typical hairpin curve into the descending branch)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4109166&req=5

Figure 2: Digital subtraction angiography (DSA) of the left L2 artery in anterior–posterior projection showing a dural arteriovenous fistula (lower arrow) at the left foramen L2-L3 and the AA (upper arrow: note this artery's vertical course and typical hairpin curve into the descending branch)
Mentions: Magnetic resonance imaging (MRI) of the spine showed marked edema and patchy contrast agent enhancement of the spinal cord from the T7 level to the conus medullaris, and enlarged perimedullary veins predominantly on the left side [Figure 1]. Spinal angiography revealed an SDAVF in the left L2-L3 intervertebral foramen, fed by a branch from the second lumbar segmental artery (L2) on the left [Figure 2]. From the very same segmental artery, the artery of Adamkiewicz (AA), a main supplier of the ASA system, branched off about 0.5 cm proximal to the fistula. Due to this anatomical particularity, endovascular embolization of the fistula was considered contraindicated and microsurgical treatment was opted for.

Bottom Line: Microsurgical disconnection of the SDAVF was attempted, but failed.All procedures were neurologically uncomplicated.The patient presented good, but incomplete neurological improvement.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University Hospital, Linköping, Sweden.

ABSTRACT

Background: Effective management of a spinal dural arteriovenous fistula (SDAVF) can be accomplished with either microsurgery or endovascular embolization, but there is a consensus that in patients in whom a radiculomedullary artery supplying the anterior spinal artery (ASA) originates from the same feeding artery as the SDAVF, the endovascular approach is to be avoided.

Case description: The patient was a 46-year-old woman with progressive lower limb paraparesis, sensory deficit, and sphincter dysfunction. Magnetic resonance imaging (MRI) and spinal angiography showed an SDAVF fed by a branch from the left second lumbar segmental artery, and the artery of Adamkiewicz (AA), a major ASA supplier, originating from the same segmental artery just proximal to the SDAVF. Microsurgical disconnection of the SDAVF was attempted, but failed. Embolization with cyanoacrylates was done in two occasions, the first time through a microcatheter placed just distal to the origin of the AA and the second time through another feeder coming from the same segmental artery that could not be visualized in the previous angiographies. All procedures were neurologically uncomplicated. Magnetic resonance imaging (MRI) 1 month after the last embolization showed resolution of the spinal cord edema. MRI scan taken 68 months after embolization revealed a slightly atrophic spinal cord with visible central canal and no recurrence of medullary edema. The patient presented good, but incomplete neurological improvement.

Conclusion: Microsurgery is the first choice for an SDAVF branching off the same radiculomedullary artery supplying the ASA, but uncomplicated embolization can be feasible after failed surgery.

No MeSH data available.


Related in: MedlinePlus