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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

(a) Superselective angiography via the microcatheter at the fistula just before embolization; (b) DSA of the left lumbar artery after fistula embolization showing intact AA
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Figure 3: (a) Superselective angiography via the microcatheter at the fistula just before embolization; (b) DSA of the left lumbar artery after fistula embolization showing intact AA

Mentions: On spinal angiography, the same SDAVF as before was visualized, still intact, and the AA branched off the same artery about 0.5 cm proximal to the fistula site [Figure 3a]. It was decided to attempt embolization past the branching point of the AA. The segmental artery supporting the fistula was catheterized using a 4 F catheter. A microcatheter (UltraFlow 1.5 F, used with guidewire Mirage, both from Micro Therapeutics, Inc., Irvine, CA, USA) was navigated into the fistula just distally to the origin of the AA [Figure 3a]. Embolization was done using 0.1 ml glue (50% N-butyl-2-cyanoacrylate and methacryloxysulfolane in Lipiodol: Glubran-2®, GEM Srl, Viareggio, Italy, and Lipiodol® Ultra-Fluide, Laboratoire Gerbet, Aulnay-Sous-Bois, France), and the distal feeder and the fistula were filled over a length of 1 cm. The microcatheter was removed and final angiography through the guide catheter showed adequate flow to the ASA and no remaining SDAVF [Figure 3b]. Postoperatively, her neurological status remained unchanged. The patient was transferred to her local hospital for rehabilitation.


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)

(a) Superselective angiography via the microcatheter at the fistula just before embolization; (b) DSA of the left lumbar artery after fistula embolization showing intact AA
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: (a) Superselective angiography via the microcatheter at the fistula just before embolization; (b) DSA of the left lumbar artery after fistula embolization showing intact AA
Mentions: On spinal angiography, the same SDAVF as before was visualized, still intact, and the AA branched off the same artery about 0.5 cm proximal to the fistula site [Figure 3a]. It was decided to attempt embolization past the branching point of the AA. The segmental artery supporting the fistula was catheterized using a 4 F catheter. A microcatheter (UltraFlow 1.5 F, used with guidewire Mirage, both from Micro Therapeutics, Inc., Irvine, CA, USA) was navigated into the fistula just distally to the origin of the AA [Figure 3a]. Embolization was done using 0.1 ml glue (50% N-butyl-2-cyanoacrylate and methacryloxysulfolane in Lipiodol: Glubran-2®, GEM Srl, Viareggio, Italy, and Lipiodol® Ultra-Fluide, Laboratoire Gerbet, Aulnay-Sous-Bois, France), and the distal feeder and the fistula were filled over a length of 1 cm. The microcatheter was removed and final angiography through the guide catheter showed adequate flow to the ASA and no remaining SDAVF [Figure 3b]. Postoperatively, her neurological status remained unchanged. The patient was transferred to her local hospital for rehabilitation.

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