Aminoff-Logue Scale Research Articles

Combined Endovascular and Surgical Treatment of Type I Spinal Dural Arteriovenous Fistulas

Introduction Spinal dural arteriovenous fistulas (SDAVFs) are rare but most common form of spinal vascular malformations, accounting for approximately 70% of all such lesions. They are low-flow vascular shunts fed by radicular arteries. Patients most often present with myelopathy. The presumed pathophysiological mechanism is venous hypertension and congestion of the cord with edema. We present our experiences and results in combined endovascular and surgical treatment of type I SDAVFs. Patients and Methods We conducted a retrospective review of prospectively collected data from patients with a diagnosis of SDAVFs who underwent treatment at University Hospital Centre Rebro Zagreb between January 2012 and June 2014. The complication and recurrence rates from clinical and imaging follow-up in these patients are analyzed. Results A total of 14 patients with a diagnosis of SDAVFs were treated in our institution during the analyzed period. Of these, 12 patients underwent endovascular embolization as first-line therapy. Onyx was used in 1 patient and NBCA in 11 patients. Two patients underwent surgical ligation as the initial therapeutic procedure. Patients in both groups showed significant improvement in clinical status after treatment on the Aminoff-Logue Scale. One patient in the endovascular group developed spinal infarction because of the accidental embolization of posterior spinal artery. Six patients in embolization group had recurrence of the fistula during the course of follow-up requiring surgical ligation. Two patients in the surgical group had recurrence of fistula during the course of follow-up and were reoperated. Conclusion Although most type I SDAFs are amenable to endovascular embolization, microsurgical obliteration as first option is indicated in specific anatomic situations and usually the only solution for recurrent cases. The combined endovascular and microsurgical approach offers best results after careful selection of patients based on imaging.

Surgical Treatment of Spinal Dural Arteriovenous Fistula: Management and Long-Term Outcome in a Single-Center Series

To perform a retrospective chart review of surgically treated patients with spinal dural arteriovenous fistula (SDAVF), a rare disease but the most common vascular malformation of the spine, focusing on clinical characteristics and functional outcome during long-term follow-up. Between June 1990 and April 2012, 29 patients with SDAVFs were treated surgically in a single institution. Patient characteristics, time from onset of symptoms to treatment, radiologic features, treatment-related complications, and functional outcome were analyzed. Outcome was assessed according to the Aminoff-Logue scale during follow-up. Results of magnetic resonance imaging scans performed during long-term follow-up were correlated with functional outcome. There were 3 female (10%) and 26 male (90%) patients with SDAVFs treated surgically. Mean age was 61 years ± 11. Location of the fistula was at the thoracic level in 20 patients (69%), at the lumbar level in 8 patients (28%), and at the sacral level in 1 patient (3%). Mean postoperative Aminoff-Logue scale scores regarding gait and micturition improved after treatment compared with preoperatively (P = 0.02; P = 0.03). After surgical treatment, 22 patients (76%) achieved improvement in neurologic symptoms. In 6 patients (21%), neurologic status was the same as preoperatively. In 1 patient (3%), neurologic status worsened. Medullary signal alteration of diagnostic magnetic resonance imaging scans did not correlate with functional outcome (P = 0.2). Mean follow-up time was 63 months ± 55. All SDAVFs were treated in a single session without recurrence during the long-term follow-up period. Surgical treatment of SDAVFs is safe and effective and leads to an improvement of neurologic symptoms in most patients. Surgical treatment of SDAVFs also provides long-term stability.

Spinal dural arteriovenous fistula: correlation between radiological and clinical findings.

The pathophysiology of spinal dural arteriovenous fistulas (SDAVFs) results in perimedullary venous congestion and in turn central cord congestion. Clinically, this presents with progressive neurological dysfunctions that, if diagnosed in a timely fashion, can be at least halted and in part reversed. In SDAVFs, imaging features on MRI and digital subtraction angiography (DSA) have not been studied in conjunction with clinical findings. The primary purpose of the present study was to test if severity of clinical presentation varies in relation to imaging. This retrospective cohort study identified 12 patients treated for SDAVF at the authors' institution. The extent of venous congestion and cord edema was quantified by the number of vertebral levels shown to be affected on DSA and MRI. A modified Aminoff-Logue Scale (ALS) score was assigned at the time of diagnosis and again after definitive therapy. The patients were divided into one of two groups: those with venous congestion < 7 and ≥ 7 vertebral levels seen on DSA and MRI and with central cord edema < 6 and ≥ 6 levels. A t-test was used to assess for a difference in the presenting ALS score between the groups. Patients with ≥ 7 levels of venous congestion reported greater functional disability (DSA: p ≤ 0.001, Cohen's d = 0.509; and MRI: p ≤ 0.001, d = 0.632). Patients with a greater extent of cord edema also reported worse functional disability (p ≤ 0.001, d = 2.31). There was a strong linear correlation between the post- and pretreatment ALS scores (R(2) = 0.86) for those with successful interventions (n = 9). In patients with an SDAVF, the severity of the neurological dysfunction may be predicted by the extent of DSA- and MRI-documented venous congestion and cord edema. There was a strong positive relationship between initial and posttreatment neurological dysfunction.

Endovascular Treatment of Spinal Arteriovenous Malformations

Background: Spinal arteriovenous malformations (AVMs) are a rare and enigmatic disease entity. These lesions can be a significant cause of myelopathy and their initial symptoms mainly include sensory loss and motor weakness. The treatment of spinal AVMs has improved tremendously. However, the choice between surgical treatment and embolization remains a matter of debate. Objectives: The aim of this study is to investigate the outcome of the endovascular management of these lesions. Patients and Methods: We report on 18 patients with spinal-AVM in whom the diagnosis was confirmed by using spinal-MRI/angiography. Patient age ranged from 19 to 73 years. All patients underwent embolization with glue/onyx. Before and after the operation, patients were followed using Aminoff Logue scale to measure clinical outcome and spinal-MRI to evaluate the feature of the lesion. Results: There was significant difference between the clinical scores (based on AminoffLogue scale) of before and after operations (P < 0.01). This significant change is seen in both short and long-term follow-up. Temporary clinical deterioration was found in one patient. Our data showed that the efficacy of this method in long-term follow-up is about 90%. Conclusions: Endovascular embolization is an effective therapeutic procedure in the treatment of spinal AVMs.

Quality of life in adult intradural primary spinal tumors: 36-Item Short Form Health Survey correlation with McCormick and Aminoff-Logue scales

The most appropriate method to determine the quality of life of patients with intradural primary spinal tumors (IPSTs) is not still well established. Clinical data in 234 patients who underwent surgery for intradural spinal disease were collected prospectively. The 36-Item Short Form Health Survey (SF-36), a generic score scale, was administered to 148 patients with IPSTs to demonstrate if the survey can be used to effectively evaluate these patients. Forty-eight patients were excluded because they did not complete the protocol. The study was finally conducted with 100 patients (45 male and 55 female) with IPSTs, and the results were compared with those of 2 other scales: the McCormick scale and the Aminoff-Logue scale. Construct validity was demonstrated by confirming the hypothesized relationship between the scores of the SF-36 and the McCormick scale (p = 0.003), the Aminoff-Logue gait subscale (p = 0.025), the Aminoff-Logue micturition subscale (p = 0.013), and the Aminoff-Logue defecation subscale (p = 0.004). Reliability was demonstrated for all 8 SF-36 domain scales and the Physical Component Summary and the Mental Component Summary of the SF-36, where in each the Cronbach alpha satisfied the Nunnally criterion of > 0.85. The authors' results demonstrated that SF-36 provides valid and reliable data for patients with IPSTs and that the survey can be used appropriately to evaluate these patients.

Correlation between time to diagnosis and rehabilitation outcomes in patients with spinal dural arteriovenous fistula

BackgroundSpinal dural arteriovenous fistulas (SDAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy although they are under diagnosed. Surgical or embolization treatment of SDAVFs improved significantly in the last decade. However, a high percentage of patients are still left with severe disability.ObjectiveTo describe the correlation between time to diagnosis and the rehabilitation outcomes of eight patients with SDAVFs.DesignRetrospective chart study of all SDAVF patients in 20 years.SettingA tertiary university rehabilitation center.Main outcome measuresThe lower extremities motor score (LEMS), Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM) and Walking Scale for Spinal Cord Injury (WISC II). Overall prognosis was evaluated using the Aminoff-Logue scale (ALS).ResultsThere were seven men and one woman with mean age of 61.3 ± 15 (30–72) and mean time until the diagnosis of SDAVF of 265.5 ± 245 days (4–730). At the end of rehabilitation period, five of the eight patients remained wheelchair dependent. Strong correlation was found between LEMS, FIM, SCIM, and WISC II scores and the functional level according to the ALS scale. A significant correlation was found between time to diagnosis and the height of the SDAVF, the clinical and rehabilitation outcomes. Patients with high SDAVF which were diagnosed late had the poorest prognosis.ConclusionsThe potential for functional ambulation in patients with SDAVF is related to the time of intervention. This finding emphasizes the important of early diagnosis and early intervention in SDAVF.

Surgical and endovascular treatment of spinal dural arteriovenous fistulas

Objective To evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas (SDAVFs) who underwent surgery,catheter embolization,and discuss the treatment modality of SDAVF.Methods The clinical data about treatment and outcomes of 11 consecutive patients with spinal dural arteriovenous fistula treated from 2007 to 2010 were analyzed retrospectively.Results The male/female ratio was 10/1.The range of patient age was from 33 to 67 years and the mean patient age was 53 years.Ali 11 cases were finally diagnosed with selectively spinal angiography.9 cases underwent microsurgery,and 2 cases underwent endovascular embolization.The clinical outcome was assessed by using the modified Aminoff Logue scale (ALS) for myelopathy.Improvement of spinal fuction occured in all 11 patients after treatment.The follow-up was carried out in ll patients for 6-24months and showed no recurrence.Conclusions Both endovascular and surgical treatment of SDAVFs let to a good clinical outcome.Penetration of the glue into the draining vein is needed for permanent closure of the fistula in embolization of some selected cases of SDAVF. Key words: Spinal dural arteriovenous fistula; Treatment; Microsurgery; Embolization

Spinal dural arteriovenous fistulas and intrathecal venous drainage: correlation between digital subtraction angiography, magnetic resonance imaging, and clinical findings

Spinal dural arteriovenous fistulas (SDAVFs) cause myelopathy through arterialization of the perimedullary venous plexus and venous congestion of the spinal cord. The authors hypothesized that the craniocaudal extent of engorgement of intrathecal draining veins between the fistula site and the point of drainage out of the thecal sac correlates with the degree of myelopathy. A retrospective review of the authors' institution's radiology databases identified 31 patients with SDAVFs who had undergone digital subtraction angiography (DSA) and MRI examinations of the spine. The authors counted the number of vertebral body levels of spinal cord enhancement and intrathecal vessel enhancement on T1-weighted postcontrast MRI studies. They also counted the number of levels of cord hyperintensity and intrathecal flow voids on T2-weighted MRI studies. On DSA, the authors identified the number of vertebral body levels of dilated intrathecal draining veins and outflow points from intrathecal veins to epidural veins. Functional status of the patients at the time of diagnosis was assessed using the Aminoff-Logue scale (ALS). Enlargement of the intrathecal draining veins averaged 10 ± 7.7 spinal levels on DSA. Patients with enlarged draining veins extending 10 or more spinal levels on DSA had worse ALS scores (mean gait 3.4, mean micturition 1.5) than patients with draining veins extending fewer than 10 levels (mean gait 1.8, mean micturition 0.6; p = 0.009 and 0.02, respectively). The number of vertebral body levels of enlarged draining veins correlated with the ALS score (gait r = 0.42, p = 0.009; and micturition r = 0.55, p = 0.0006). More extensive enlarged draining veins were associated with more spinal cord T2 hyperintensity, T2 intrathecal flow voids, and T1 vessel enhancement but not cord enhancement. The craniocaudal extent of enlarged intrathecal veins draining SDAVF correlates with patient functional status, providing further insight into the pathophysiology of venous hypertensive myelopathy.

Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature

Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease. Functional outcome is particularly uncertain for the small group of patients that are unable to stand at the time of diagnosis (grade 5 gait disturbance on the Aminoff-Logue scale, ALS). The objective of this study is to examine the final functional outcome of patients with SDAVF in grade 5 gait ALS before treatment. We conducted a PubMed search using the keyword "spinal dural arteriovenous fistula." A review of the clinical series and single well-detailed case reports of SDAVF gathered 106 patients with grade 5 gait ALS on the initial examination. Additionally, we report the case of a 56-year-old man presenting acute paraplegia and urinary retention on admission who had complained of sporadic motor and sphincter disturbances for 1 year. Spine T2-weighted MR imaging showed a central hyperintensity within the spinal cord, and the angiography demonstrated a T-11 SDAVF. Interruption of the fistula was performed through an urgent one-level laminectomy. Grade 5 gait ALS was present in 25% of the patients with SDAVF included in the clinical series. Latest follow-up showed that gait disturbance improved in 73% of patients after treatment, although less than 6% became grade 1 gait ALS. Micturition disturbances improved in 39%. Exploration of our patient showed improvement to grade 1 gait ALS 1 year after the surgical treatment. Interruption of SDAVF in paraplegic patients may improve the final functional gait outcome in some cases. No complete recovery (grade 0 gait ALS) was achieved after treatment. Micturition disturbances had a worse prognosis than motor deficits.

Endovascular and surgical treatment of spinal dural arteriovenous fistulas

The aim of this retrospective study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas (SDAVFs) that were treated with surgery, catheter embolization, or surgery after incomplete embolization. The study included 21 consecutive patients with SDAVFs of the thoracic, lumbar, or sacral spine who were treated in our institution from 1994 to 2007. Thirteen patients were treated with catheter embolization alone. Four patients underwent hemilaminectomy and intradural interruption of the fistula. Four patients were treated by endovascular techniques followed by surgery. The clinical outcome was assessed using the modified Aminoff-Logue scale (ALS) for myelopathy and the modified Rankin scale (MRS) for general quality of life. Patient age ranged from 44 to 77 years (mean 64.7 years). Surgical as well as endovascular treatment resulted in a significant improvement in ALS (-62.5% and -31.4%, respectively, p < 0.05) and a tendency toward improved MRS (-50% and -32%, respectively) scores. Patients that underwent surgery after endovascular treatment due to incomplete occlusion of the fistula showed only a tendency for improvement in the ALS score (-16.7%), whereas the MRS score was not affected. We conclude that both endovascular and surgical treatment of SDAVFs resulted in a good and lasting clinical outcome in the majority of cases. In specific situations, when a secondary neurosurgical approach was required after endovascular treatment to achieve complete occlusion of the SDAVF, the clinical outcome was rather poor. The best first line treatment modality for each individual patient should be determined by an interdisciplinary team.

Long-term outcome of a multidisciplinary concept of spinal dural arteriovenous fistulae treatment

The optimal treatment of spinal dural arteriovenous fistulae (SDAVF) remains controversial and long-term follow-up data, especially data from multidisciplinary treatment, are rarely available. Thus, long-term outcomes following a multidisciplinary approach to the treatment of SDAVF were investigated. The investigation included 26 patients with SDAVF treated at the authors' department over a 15-year period including a follow-up of more than 2 years. The treatment strategy when occlusion of the draining vein could be achieved was to embolize the fistula with Histoacryl, with surgery reserved for those patients unsuitable for embolization. Posttreatment angiography followed by MRI was performed in all patients. Clinical follow-up was performed using the gait and micturition Aminoff-Logue scale scores and the modified Rankin scale score. Embolization was performed in 19 patients (73.1%), and direct surgery in 7 patients (26.9%). Follow-up angiography (at a mean of 21.7 months) showed occlusion of the SDAVF in 24 patients (92.3%). Of the 19 embolized patients, 2 (10.5%) developed recurrence secondary to insufficient occlusion of the SDAVF draining vein, and one of these two patients underwent re-embolization and one re-operation. No negative effects of SDAVF recurrence on the final clinical outcome were identified in either patient. MRI after angiography (at a mean of 91.5 months) demonstrated occlusion of all SDAVFs. After a mean clinical follow-up of 103.4 months there was a statistically significant improvement in both the modified Rankin scale score and the Aminoff-Logue gait scale score (P < 0.05). The present multidisciplinary study showed for the first time that embolization leads to stable neuroradiological results and favourable clinical outcomes even for very long follow-up times of more than 100 months. Microsurgery remains the treatment of choice when safe embolization of the draining vein cannot be achieved.

Clinical and Radiographic Features of Dural Arteriovenous Fistula, a Treatable Cause of Myelopathy

To assess presentation, imaging, treatment, and outcome of patients with myelopathy due to a dural arteriovenous fistula (DAVF). This retrospective review identified 94 patients with DAVF surgically treated at our institution between June 1985 and December 1999. The mean ages of the 75 men and 19 women were 62.6 years and 63.0 years, respectively (range, 31-83 years). Magnetic resonance imaging was performed in 87 patients, computed tomography-myelography was performed in 37 patients, and spinal angiography was performed in all patients. Initial examination findings were retrospectively adjusted to a modified Aminoff-Logue myelopathy scale. Of the 94 patients, 47 presented with symptoms that worsened with erect posture or Valsalva maneuver. As myelopathy progressed, patients' symptoms increased, and 6 patients had paraplegia at presentation. The mean time from symptom onset to diagnosis was 23 months (range, 2-120 months). Magnetic resonance imaging confirmed the diagnosis in 86 patients; computed tomography-myelography was needed to confirm the fistula in 1 patient. Spinal angiography detected the fistula in all patients. Surgical obliteration of the DAVF was successful in 93 patients; in 1 patient surgery failed because the DAVF was not localized, but acrylic endovascular embolization was successful. No patient experienced permanent morbidity or mortality. Of the 94 patients, 93 improved postoperatively 1 or 2 levels based on a modified Aminoff-Logue scale. Older patients with severe long-term deficits had poor outcomes. The diagnosis of a DAVF seems to be delayed considerably because DAVF is not included in the differential diagnosis of myelopathy and because of clinicians' unfamiliarity with suggestive or revealing findings on diagnostic imaging. Neurodiagnostic imaging confirms the diagnosis, and spinal angiography localizes the fistula. Surgical intradural disconnection of the DAVF clinically reverses the pathophysiology. Additionally, surgical treatment is associated with low short-term morbidity, no permanent morbidity, and no mortality. If the diagnosis is made early and treatment initiated in such patients, they generally do well.

Surgical and endovascular treatment of spinal dural arteriovenous fistulas: long-term disability assessment and prognostic factors.

The authors assessed clinical outcomes of patients with treated spinal dural arteriovenous fistulas (DAVFs) and investigated prognostic factors. Thirty consecutive patients with spinal DAVFs were treated at the authors' institution during the past 15 years: seven underwent surgery; seven underwent surgery after failed embolization: and 16 underwent embolization alone. The outcomes of gait and micturition disability, were analyzed. Follow up averaged 3.4 years (range 1 month-11.8 years). Age, duration of symptoms, pre- and postintervention magnetic resonance (MR) imaging findings, and preintervention disability were correlated with outcome. Seventeen patients (57%) experienced improved gait, 12 (40%) were unchanged, and one (3%) was worse. In 11 patients (37%) micturition function was improved, in 15 (50%) it was unchanged, and in four (13%) it was worse. Gait disability, as measured by the Aminoff-Logue Scale, was significantly improved after treatment, from 3.4+/-1.4 (average +/- standard deviation) to 2.7+/-1.5 (p = 0.007). Mean micturition disability scores decreased, but not significantly, from 1.9+/-1 to 1.6+/-1.1 (p = 0.20). Preintervention gait disability was not associated with improvement except for patients with Aminoff-Logue Scale Grade 4 disability (eight of nine improved; p = 0.024). For patients treated within 13 months of symptom onset, mean micturition disability decreased (p = 0.035). No association was found between clinical improvement and age, a symptom duration less than 30 months, or pre- and postintervention MR imaging-documented spinal cord edema. Spinal DAVF treatment significantly improved patients' mean gait disability score by almost one grade at last follow up. The mean micturition disability score was not significantly improved, unless treatment was performed within 13 months of symptom onset. Longer and more uniform follow-up study is needed to determine if improved and stabilized clinical outcomes are sustained.