The Impact of Magnetic Resonance Imaging Findings in Predicting Neurological Status Pre- and Post-Treatment of Spinal Dural Arteriovenous Fistulas: A 22-Year Experience in a Neurovascular and Spine Center.

Abstract

Successful treatment of spinal dural arteriovenous fistulas (SDAVF) requires prompt diagnosis with definitive fistula localization and non-delayed treatment. Magnetic resonance imaging (MRI) is used for the screening and follow-up of SDAVF, although the value of MRI signs such as myelopathy and flow voids is controversial. Therefore, we investigated the predictive value of MRI signs pre- and post-treatment and their correlation with the neurological status of SDAVF patients. We retrospectively analyzed the clinical records of 81 patients who underwent surgical or endovascular treatment for SDAVF at our hospital between 2002 and 2023. A total of 41 SDAVF patients with follow-up MRI of 4.6 [2.9-6.5] months (median [interquartile range]) post-treatment and clinical follow-up of 3, 6, and 12 months were included. The extent of pretreatment myelopathy was seven [6-8] vertebral levels, with follow-up MRI showing no myelopathy in 70.7% of cases. The pretreatment flow voids extended over seven [4.5-10] vertebral levels and completely disappeared on follow-up MRI in 100% of cases. The modified Aminoff-Logue scale of disability (mALS) was four [2-7] pretreatment and two [0-4.5] at the third follow-up, with improvement in 65.9% of patients. The American Spinal Injury Association motor score (ASIA-MS) was 97 [88-100] pretreatment and 100 [95-100] at the third follow-up assessment, with 78% of patients improving. Pretreatment ASIA-MS correlated with the extent of myelopathy at admission (R2: 0.179; 95% CI: -0.185, -0.033; p = 0.006) but not with flow voids at admission, while pretreatment mALS showed no correlation with either MRI signs. The improvement in ASIA-MS and mALS between admission and the last follow-up showed no correlation with the extent of pretreatment myelopathy and flow voids or with pos-treatment MRI changes. The diagnostic sensitivity of magnetic resonance angiography (MRA) for localization of the fistula was 68.3% (28/41). The severity of the clinical condition in SDAVF patients has a multifactorial cause, whereby the ASIA-MS correlates with the extent of myelopathy pretreatment. MRI changes after treatment showed no correlation with the clinical outcome and cannot be used as a prognostic factor.