Combined Endovascular and Surgical Treatment of Spinal Dural Arteriovenous Fistulas

Abstract

IntroductionType I spinal dural arteriovenous fistulas (SDAVFs) are the most common form of spinal vascular malformations. Even so, they are rare and still underdiagnosed. They are low-flow vascular shunts fed by radicular arteries in patients who most often present with myelopathy. Left untreated, they can lead to progressive neurological decline and considerate morbidity. We present our experiences and results in combined endovascular and surgical treatment of such lesions. Material and MethodsWe conducted a retrospective review of data from 14 adult patients with the diagnosis of SDAVFs who underwent treatment at University Hospital Center Rebro Zagreb between January 2012 and June 2014. We compared complication rates, recurrence rates and data on clinical and imaging follow up in these patients. Results12 out of 14 patients underwent endovascular embolization (Onyx was used in 1 patients and NBCA in 11 patients) as the first line therapy. Two patients underwent surgical ligation as initial therapeutic modality. Patients in both groups showed significant improvement in clinical status after treatment (using the Aminoff-Logue Scale score). One patient in endovascular group developed spinal infarction due to accidental embolization of posterior spinal artery. Six patients in embolization group had recurrence of fistula during the course of follow up requiring surgical ligation. Two patients in surgical group had recurrence of fistula during the course of follow- up and were reoperated. ConclusionDespite most fistulas are amenable to endovascular embolization, microsurgical obliteration is the treatment of choice in specific anatomic situations and usually the only solution in recurrent cases. A combined approach offers the best results after careful selection of patients based on imaging.