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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

T2-weighted MRI of the spine: (a) midline sagittal image showing less-intensive swelling but persistent edema signal on the conus medullaris; (b) parasagittal image on the left showing dilated perimedullary veins indicative of persistent SDAVF
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Figure 4: T2-weighted MRI of the spine: (a) midline sagittal image showing less-intensive swelling but persistent edema signal on the conus medullaris; (b) parasagittal image on the left showing dilated perimedullary veins indicative of persistent SDAVF

Mentions: The patient did not improve clinically, and dysesthesia, walking difficulties, urinary incontinence and fecal retention remained as before embolization. Follow-up MRI done 2, 6, and 11 months later showed markedly less-intensive engorgement of the spinal cord, but persistent signal changes compared to previous examinations. Since the latest MRI also showed clearly dilated perimedullary veins on the left side [Figure 4], we decided to perform a new spinal angiography.


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)

T2-weighted MRI of the spine: (a) midline sagittal image showing less-intensive swelling but persistent edema signal on the conus medullaris; (b) parasagittal image on the left showing dilated perimedullary veins indicative of persistent SDAVF
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 4: T2-weighted MRI of the spine: (a) midline sagittal image showing less-intensive swelling but persistent edema signal on the conus medullaris; (b) parasagittal image on the left showing dilated perimedullary veins indicative of persistent SDAVF
Mentions: The patient did not improve clinically, and dysesthesia, walking difficulties, urinary incontinence and fecal retention remained as before embolization. Follow-up MRI done 2, 6, and 11 months later showed markedly less-intensive engorgement of the spinal cord, but persistent signal changes compared to previous examinations. Since the latest MRI also showed clearly dilated perimedullary veins on the left side [Figure 4], we decided to perform a new spinal angiography.

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