Selective Spinal Angiography Research Articles

Spinal arteriovenous malformations

Spinal vascular malformations include various entities such as spinal arteriovenous malformations (AVM) and represent arare disease. Patients may present with acute or progressive sensorimotor deficits and/or nonspecific symptoms such as hypoesthesia or paresthesia, diffuse back and muscle pain, or feelings of weakness. When spinal arteriovenous malformation is suspected, magnetic resonance imaging (MRI) is the first diagnostic step to rule out other differential diagnoses, followed by aselective spinal angiography. Therapeutic options include endovascular therapy by embolization and/or surgical resection. If spinal AVM is treated properly, asignificant reduction in symptoms can be achieved.

Cauda Equina Arteriovenous Malformation with Bilateral Arterial Feeders

Cauda equina arteriovenous malformation (AVM) is extremely rare. To our knowledge, only 2 cases have been reported previously and are supplied by a unilateral lateral sacral artery (LSA). Here, we report a rare cauda equina AVM at the level of L5-S1, which is supplied by the bilateral LSAs. Given the multiple feeders and complex angioarchitecture, endovascular embolization was performed with Onyx (ev3) successfully. The postoperative course of the patient was uneventful, and symptoms gradually improved. The present case demonstrated the angioarchitecture of the bilateral arterial supplies and venous drainage of the cauda equina AVMs. Cauda equina AVM with bilateral arterial feeders is extremely rare. However, clinicians should be aware of the possibility of this condition and the importance of selective spinal angiography of bilateral LSAs.

Combined treatment of hypervascular spinal tumors. Our experience

Objective – to increase the feasibility and safety of surgical treatment and to achieve better clinical outcome in patients with hypervascular spine tumors by combining managed endovascular embolization followed by surgery.Materials and methods. We enrolled 10 patients (6 men and 4 women, the average age was 57 years) with hypervascular spinal tumors who underwent examination and treatment at SO «Scientific-Practical Center of Endovascular Neuroradiology of NAMS of Ukraine» during the period from 2015 to 2019. Five patients have aggressive vertebral hemangiomas (L1, L2, Th12, Th 7, Th 6) and 5 patients have metastases of renal cell carcinoma of the vertebrae (Th4, Th10, Th12, L3) were included. Medical history and neurological status were evaluated, but in all cases the clinical diagnosis was made according to MRI and spine CT. In addition, all patients underwent selective spinal angiography via transfemoral access at the level of the lesion and in at least two adjacent levels. All patients underwent endovascular embolization of the tumor as the first step and open surgery in the volume of biopsy, decompression, and stabilization of the spine in the second stage. The volume of blood loss in ml was estimated by the anesthesiologist.Results. According to the localization of the lesions, spinal angiography showed a high accumulation of contrast fluid in its structure, compared to surrounding tissues, in all cases. This is evidence of the presence of a hypervascular lesion. All patients underwent the combination treatment – preventive endovascular embolization followed by surgery. In 9 cases embolization was performed 24–36 hours before surgery. Due to the patient’s somatic condition, open surgery was delayed once by 5 days. The total embolization of the tumor vasculature in 7 cases was achieved, with a subtotal embolization in 3 cases. Partial embolization was performed in one case of aggressive hemangioma when the afferent was involved in the blood supply of the spinal artery. Reversible deeper neurologic deficits following embolization in 4 cases was observed. Two patients noticed the reduction of the pain immediately after embolization. Mean intraoperative blood loss was 500 ml during the second stage of treatment. Blood loss was 600 ml in the case of delayed surgery. In all cases, the control of bleeding didn’t interrupt adequate decompression and transpedicular stabilization if it was required, and none of the surgical stages were delayed or canceled because of bleeding. Residual bleeding persisted from the venous system and tumor-related tissues.Conclusions. Preoperative embolization of hypervascularized tumors is a safe and effective method to reduce perioperative hemorrhage, which in turn leads to the reduction of the duration of surgery, improves the visualization of the surgical field, allows the performance of all steps of open surgery and achieve a positive clinical result. The mean blood loss was lower compared to procedures without preoperative embolization, according to published papers on surgery of hypervascular spinal tumors. Embolic agents (mixture of Histoacryl and Lipiodol and polyvinyl alcohol (PVA)) have shown high efficacy to control arterial bleeding, with residual bleeding from the venous system.

Challenges in Management of Epithelioid Hemangioendothelioma of the Spine: The Report of a Rare Cause of Cauda Equina Syndrome

Introduction: Epitheliod hemangioendothelioma (EHE) is a rare spinal neoplasm with vascular provenance, which can present as a primary lesion or metastatic lesion with the secondary involvement of the liver, lung, and long bones. EHE can occur all over the spine from the craniovertebral junction to the lumbosacral area. Usual presenting symptoms are back pain, pathologic fractures, myelopathy, and cauda equina syndrome. Diagnosis and management can be difficult, often requiring coordination between multiple disciplines for selective spinal angiography, surgical resection, the establishment of pathologic diagnosis, and adjuvant treatment, if necessary. There are no widely accepted guidelines for the management of EHE. Case Presentation: We report a 43-year-old male as a case of primary unifocal hemangioendothelioma with two unique features compared to previous reports: first, the presentation with acute cauda equine syndrome and second, the involvement of posterior elements, which made it very difficult to differentiate from aneurysmal bone cyst (ABC). Conclusions: We review the existing literature on spinal EHE, present management challenges via case review, and propose a management guideline for neurosurgeons, interventional radiologists, pathologists, and radiation oncologists to streamline the diagnosis and management of EHE of the spine.

Pure spinal extradural arteriovenous malformation in the thoracolombar region: a case report

Pure extradural spinal arteriovenous malformations (AVMs) are formed with an epidural artery, a nidus and an arterialized intradural vein in the absence of vertebral cavernous hemangioma and uncommon lesions. The most common extradural tumors are metastasis, lymphomas, benign tumors and malignant bony tumors. Herein, we present a-29-year-old Turkish woman with pure extradural mass that histopathologically diagnosed as AVM. When an extradural spinal compressive mass is detected, neurosurgeons should consider on AVM in differential diagnosis and requirement of selective spinal angiography.

Endovascular surgery of spinal dural arteriovenous fistulas

To evaluate the efficacy of endovascular treatment of SDAVFs, depending on the pathophysiological mechanisms of impact on the spinal cord. For the last 5 years (2013-2017), 302 patients with SDAVFs were diagnosed and treated at the Neurosurgical Institute. The endovascular technique was used in 295 patients with this pathology. Males accounted for 82%; females accounted for 18%; the mean age was 51 years. Magnetic resonance imaging (MRI) was used to assess the degree of spinal cord involvement. All SDAVF patients underwent total selective spinal angiography in order to study angioarchitectonics and to choose an endovascular treatment option. Endovascular embolization of fistulas was performed in 295 out of 302 patients; direct surgery was used in the remaining cases. Endovascular treatment provided total SDAVF occlusion in 78% of cases and partial SDAVF occlusion in 22% of cases. Long-term outcomes were followed-up in all patients in a period of 6 to 12 months. In 90% of cases, improvement or stabilization of neurological symptoms was observed. In 60% of cases, there was a marked improvement in the neurological status in the form of rapid (within a few days) recovery of lost motor functions. The remaining patients had stabilization of clinical symptoms.

Spinal arteriovenous malformations: surgical outcome

Spinal arteriovenous malformations are relatively rare, being one tenth as common as cerebral AVMs and one tenth as common as primary spinal neoplasms. The aim of this retrospective study was to see distribution of this disease in spinal cord and analyse outcome of surgical treatment in our set-up. 5 patients with neurologic deficit due to spinal AVMs were operated upon from March 2000 to Feb 2005. Age ranged from 25-45 years with mean of 35 years. There were 2 females and 3 males with sex ratio of 1:1.5 respectively. Spinal AVMs were categorized as one of 4 types based on pattern of arterial and venous supply. We found that 60% (3 cases) in our series were intradural AVMs while 40% (2 cases) were dural type. We conclude that glomus variety of intradural AVMs was the commonest. The commonest presentation was acute spinal dysfunction and paraparesis. Selective spinal angiography can be negative in spinal AVMs, (20%) in our series, in which CT angiography provided clue to the feeding vessels.

Surgical Management of the Spinal Cord Vascular Lesions Supplied by the Anterior Spinal Artery

Introduction Surgical management of the spinal cord (SC) vascular malformations supplied by the anterior spinal artery (ASA) is still disputable and technically demanding. Treatment options include endovascular, open surgical, or a combination of the two methods. All options have a risk of SC ischemia resulting from retraction or dissection through the SC, coagulation or embolization of the SC supplying artery. The authors consider surgery to be an ultimate solution for this pathology. We present four patients with symptomatic anteriorly placed vascular malformations in which total excision of the lesions was performed by a posterolateral approach with unilateral arthropediculectomy. Materials and Methods The case series included 4 patients (2 male, 2 female), ages 23–56 (mean 32). All patients initially presented with weakness in the lower limbs and (or) pelvic organ dysfunction. The preoperative evaluation consisted of a neurologic/urodynamic evaluation, and imaging studies. In all patients the neuroimaging included magnetic resonance imaging (MRI) and selective spinal angiography (SSA), confirming the diagnosis of arteriovenous malformation in two patients, spinal hemangioma in one, and cavernous angioma in another. Vascular malformations were supplied by the ASA in 2 cases and by both the anterior and posterior spinal arteries in the other two cases. Neurologic status was based on duration of symptoms, the presence of motor, sensory or sphincter dysfunction and grading by the Frankel scale. Two patients with malformations supplied by anterior and posterior spinal arteries underwent endovascular intervention to reduce the intensity of blood flow by means of embolization. In all patients the surgery was three stage procedure made in one operative session: 1. Posterolateral approach with unilateral arthropediculectomy; 2. Microsurgical resection of the malformation; 3. Posterior instrumented fusion (to avoid postlaminectomy kyphosis). The patients were positioned prone on the Jackson table with 3-point Mayfield clamp affixed to the head placed in a neutral position, to allow adequate posterior fusion. Posterolateral approach with unilateral arthropediculectomy allowed to obtain adequate visualization of the anterior and lateral aspects of the SC for direct manipulations on the malformation and its feeding vessels, while avoiding direct manipulations on the SC or its dissection. Cervical/thoracic posterior screw fixation and fusion was performed using freehand technique considering unique osteoligamentous and vascular anatomy. None of the screws were malpositioned or interfered with post-op SSA. Results Postoperative SSA demonstrated complete disappearance of the malformation in all cases. Neurological outcome improved in all patients. Follow-up Frankel grades showed improvement to grade E in 2 patients (50%), and reached grade D in 2 (50%). Conclusion Despite the increasing use of endovascular techniques there is a significant role for operative management of spinal cord (SC) vascular malformations having complicated/combined arterial feeding. Treatment should be individualized and integrated by endovascular and surgical procedures, considering lesional angioarchitecture and clinical status of the patient. Surgical approach should provide the exposure of the anterior and lateral aspects of the SC for direct manipulations on the malformation and its feeding vessels, and exclude manipulations and dissection of the SC.

Diagnostic Inefficiency of Nonselective Spinal Angiography (Flush Aortography) in the Evaluation of the Normal and Pathological Spinal Vasculature

Selective spinal angiography was introduced in the 1960s to palliate the poor sensitivity of nonselective techniques for the evaluation of the spinal cord vasculature. Recent advances made in the field of angiography seem to have prompted a renewed interest for nonselective spinal angiography, or flush aortograms. This pictorial essay, illustrated with 2 cases of presurgical evaluation of the spinal cord supply and 2 cases of spinal vascular malformation, suggests that nonselective techniques remain insufficient to properly document the normal or pathological spinal vasculature. While flush aortography can play a role as a complement to spinal angiography, for example, to locate vessels eluding selective catheterization, relying on nonselective studies to rule out the presence of a spinal vascular malformation or to identify the normal spinal cord supply before surgical interventions may lead to false-negative investigations with potentially devastating consequences.

Special features of Foix-Alajouanine syndrome (clinical course)

The aim of the work is to improve the diagnostics of spinal AVMs. For the proper diagnosis of Foix-Alajouanine syndrome the speed of progression and the dynamics of the spinal focal neurological signs, as well as the volume of the spinal lesion should be taken into account. Evaluation of the results of additional methods of investigation: spinal MRI, spinal MR angiography, MR-tractography, etc. is also needed. Selective spinal angiography remains the optimal diagnostic method for spinal AVMs. The treatment must include anticoagulants and surgery.

Extradural spinal cavernous malformation: A rare but important mimic

Purely extradural spinal cavernous malformations (ESCMs) are rare, but the number of cases reported seems to be increasing.A 44-year-old woman presented with progressive cervicothoracic back pain, lower limb paraesthesia and hypertonia. MRI showed a well-circumscribed, convex lesion in the T1-4 extradural space causing cord compression and encroaching into the left T2/3 neural foramen. Selective spinal angiography demonstrated a vascular blush at the T2/T3 level corresponding with the mass. A feeding vessel arising from the base of the T1 spinous process was identified and successfully catheterised, but embolisation was precluded by unfavourable anatomy of the posterior spinal artery. At hemilaminectomy, the lesion was found to be an ESCM. The patient went on to make a full recovery. We reviewed 71 cases of ESCM reported in the last decade.Incidence of ESCM is unclear; the largest case series reported on nine patients, but most published accounts were single case studies. Patients presented with back pain (33%), myelopathy (56%) and/or radiculopathy (39%). Onset of symptoms was usually insidious over months to years, but 30% presented with sudden-onset neurological symptoms, often due to spontaneous haemorrhage. Mean age at diagnosis was 44 (range, 2–74; SD, 19.6) years with a 1:1 sex ratio. Lesions were found at all levels except C1–C2, but a strong predilection for the dorsal thoracic spine (68%) was shown. The lesion extended into an intravertebral foramen in at least 24 cases (34%). MRI is the investigation of choice, and angiography of ESCM has rarely been described. Most (87%) were hypo- to isointense on T1 MRI while hyperintensity on T2 (91%) and avid (89%), usually homogenous gadolinium update was almost universal. Perilesional haemosiderin, characteristic of intracranial and intramedullary cavernous malformation was rarely seen. In many cases, meningioma or nerve sheath tumour was misdiagnosed prior to surgery. All patients underwent total (95%) or subtotal (5%) microsurgical resection with excellent results; all improved (23%) or recovered fully (77%) after surgery. Those who presented acutely did worse; 38% had residual deficits.

Spinal Cord Venous Infarction Presumed to be Caused by a Lumbar Vertebral Body Malformation after Vertebral Complession Fracture

We report a case of a 81-year-old woman with a subacute bilateral legs palsy due to venous congestion of the spinal cord caused by an arteriovenous fistula in the first lumbar vertebra which fractured previously. We diagnosed her spinal infarction only by MRI. She recovered from leg palsy at first. So we waited and saw her symptom. But after that leg palsy repeated with short interval and gradually her palsy was getting worse and became completed palsy. We performed selective spinal angiography and found out arteriovenous fistula in first lumbar vertebra fractured previously. We estimated that vertebral fracture might make arteriovenous fistula in vertebral body and this fistula caused venous congestion spinal cord. Spinal cord venous infarctions due to venous congestion with lumbar vertebral body malformation is a very rare. Therefore we delayed to diagnose and this delay caused to permanent neurological deficits.

Sacral Intradural Arteriovenous Fistula Treated Indirectly by Transection of the Filum Terminale: Technical Case Report

Type A intradural arteriovenous fistulae of the sacral filum terminale are rare lesions fed primarily by the distal anterior spinal artery. The artery is frequently too narrow or tortuous for endovascular obliteration, and direct surgical resection of the fistula requires an invasive sacrectomy. We present a less invasive indirect surgical approach through an L4 laminectomy and transection of the filum terminale rostral to the fistula. A 62-year-old man presented with a 6-month history of progressive bilateral lower extremity paresthesias and weakness and associated incontinence and impotence. Spinal magnetic resonance imaging demonstrated perimedullary flow voids. Selective spinal angiography revealed a fistula at S2-3 between the distal anterior spinal artery and an early draining vein returning cranially along the filum terminale, diagnostic of an intradural arteriovenous fistula. An L4 laminectomy and transection of the filum terminale rostral to the lesion were performed to disrupt the medullary arterial supply to the intradural fistula and outflow to the medullary venous plexus of the spinal cord. At 10-month clinical follow, up the patient had regained bowel and bladder continence, was able to ambulate with a cane, and reported subjective improvement of lower extremity paresthesias. Selective spinal angiography at 1 year demonstrated no residual arteriovenous shunt. Pathological venous hypertension of a type A intradural arteriovenous fistula of the sacral filum terminale can be treated by transection of the filum terminale at L4. This avoids posterior partial sacrectomy required for direct resection; however, subsequent clinical follow-up is necessary to monitor for reconstitution.

Cauda Equina Syndrome Caused by Spinal Dural Arteriovenous Fistula

Spinal dural arteriovenous fistula (SDAVF) is rare but still the most commonly encountered vascular malformation of the spinal cord. A 31-year-old male developed gait disturbance due to weakness of his lower extremities, voiding difficulty and sexual dysfunction with a progressive course since 3 months. He showed areflexia in both knees and ankles. Electromyographic findings were suggestive of multiple root lesions involving bilateral L2 to S4 roots of moderate degree. Magnetic resonance images showed high signal intensity with an ill-defined margin in T2-weighted images and intensely enhanced by a contrast agent through the lumbosacral spinal cord. Selective spinal angiography confirmed a dural arteriovenous fistula with a nidus at the L2 vertebral level. After selective endovascular embolization, his symptoms drastically improved except sexual dysfunction. We report a rare case of cauda equina syndrome due to spinal arteriovenous fistula with drastic improvement after endovascular embolization.

Endovascular Treatment of Spinal Arteriovenous Lesions: Beyond the Dural Fistula

During the past few decades, there have been significant advances in the understanding of spinal vascular lesions, mainly because of the evolution of imaging technology and selective spinal angiography techniques. In this article, we discuss the classification, pathophysiology, and clinical manifestations of spinal vascular lesions other than DAVFs and provide a review of the endovascular approach to treat these lesions.

Use of Microscope-Integrated Near-Infrared Indocyanine Green Videoangiography in the Surgical Treatment of Spinal Dural Arteriovenous Fistulae

Identification and complete interruption of fistulae are essential but not always obvious during the surgical treatment of spinal dural arteriovenous fistulae (dAVFs). We examined cases in which we identified and confirmed surgical obliteration of a spinal dAVF with the aid of microscope-integrated near-infrared indocyanine green (ICG) videoangiography. ICG videoangiography was performed during 6 surgical interventions in which 6 intradural dorsal AVFs (type I) were interrupted. An operating microscope-integrated light source containing infrared excitation light illuminated the operating field and was used to visualize an intravenous bolus of ICG. The locations of fistulae, feeding arteries, and draining veins and documentation of occlusion of the fistulae were compared with findings on preoperative and postoperative digital subtraction angiography. ICG videoangiography identified the fistulous point(s), feeding arteries, and draining veins in all 6 cases, as confirmed by immediate postoperative selective spinal angiography. In 1 case, intraoperative ICG ruled out an additional questionable fistula at a contiguous level suspected on the preoperative angiography. Microscope-based ICG videoangiography is simple and provides real-time information about the precise location of spinal dAVFs. During spinal dAVF surgery, this technique can be useful as an independent form of angiography or as an adjunct to intra or postoperative digital subtraction angiography. Larger series are needed to determine whether use of this modality could reduce the need for immediate postoperative spinal angiography after obliteration of intradural dorsal AVFs.

Occult dural arteriovenous fistula causing rapidly progressive conus medullaris syndrome and paraplegia after lumbar microdiscectomy

A spinal dural arteriovenous fistula (DAVF) is a known cause of venous congestive myelopathy. These lesions are thought to be acquired. There exist two prior reports that describe DAVF presenting with slowly progressive myelopathy years after lumbar disc surgery. We report the first case of a preexistent, asymptomatic DAVF that became acutely symptomatic after lumbar microdiscectomy causing rapidly progressive conus medullaris syndrome and paraplegia. Case report. A 53-year-old Caucasian male presented with urinary retention, fecal incontinence, and progressive loss of function in bilateral lower extremities less than 3 months after a lumbar discectomy at an outside facility. The patient underwent microdiscectomy at L4/L5 and L5/S1 for left-sided radicular symptoms and evidence of herniated discs on magnetic resonance imaging (MRI). The patient's preoperative pain improved after the discectomy, but his bowel, bladder, and lower extremity function deteriorated steadily after discharge. Postoperative MRI showed salient serpentine vessels in the region of L1 and L2 with an enlarged T2 bright conus medullaris. Retrospective review of preoperative MRI revealed the presence of similar but less pronounced findings. A spinal arteriogram confirmed concerns of an arteriovenous malformation. The patient was transferred to our facility for definitive management of his DAVF via catheter embolization. Complete fistula obliteration was confirmed at the time of embolization and at 8 weeks follow-up with selective spinal angiography. The appearance of the conus medullaris normalized on follow-up MRI. The patient made a slow but significant recovery in rehabilitation. He regained the ability to independently ambulate but remains significantly disabled secondary to residual lower extremity weakness and spasticity. He continues self-catheterization for persistent neurogenic bladder dysfunction. This represents the first case of an occult spinal DAVF becoming acutely symptomatic after lumbar disc surgery. Although the etiology of the lesion and its symptomatic progression remains unknown, an alteration of blood flow through the DAVF as a result of surgery may have resulted in progressive venous congestive myelopathy. The present case highlights the importance of considering a spinal DAVF in the differential diagnosis of any patient with signs of myelopathy or conus medullaris syndrome after lumbar discectomy. In addition, this case underscores the gravity of recognizing subtle features that suggest the presence of an occult vascular malformation on preoperative imaging, as symptomatic progression of these lesions carries significant potential morbidity.

Endovascular management of spinal vascular malformations

Spinal vascular malformations are rare diseases with a wide variety of neurological presentations. In this article, arteriovenous malformations (both from the fistulous and glomerular type) and spinal dural arteriovenous fistulae are described and an overview about their imaging features on magnetic resonance imaging (MRI) and digital subtraction angiography is given. Clinical differential diagnoses, the neurological symptomatology and the potential therapeutic approaches of these diseases which vary depending on the underlying pathology are given. Although MRI constitutes the diagnostic modality of first choice in suspected spinal vascular malformation, a definite diagnosis of the disease and therefore the choice of suited therapeutic approach rests on selective spinal angiography. Treatment in symptomatic patients offers an improvement in the prognosis. In most spinal vascular malformations, the endovascular approach is the method of first choice; in selected cases, a combined or surgical therapy may be considered.

Conus perimedullary arteriovenous fistula in a child: unusual angio-architectural features and pathophysiology

The perimedullary arteriovenous fistulas are located on the pial surface and are usually supplied by spinal medullary arteries, that is, either by the anterior or posterior spinal arteries, with no intervening nidus between the feeder arteries and the venous drainage. The clinical findings are, more commonly, caused by progressive radiculomedullary ischemic processes secondary to steal vascular mechanism. As the vascular supply to the spinal cord and to the arteriovenous fistulas (AVF) is not shared with one another, the vascular steal phenomenon cannot be implicated in this case's physiopathology. Most probably, the mass effect caused by the giant venous dilatation was the pathophysiological mechanism involved in this lesion. The authors describe the case of a 6-year-old girl with an intradural ventral arteriovenous fistula, with a giant venous dilatation, fed directly by L2 and L3 radiculomedullary arteries at the conus medullaris. There was no arterial supply to the fistula from the anterior or posterior spinal arteries. Selective spinal angiography showed an arteriovenous fistula supplied directly by two radiculomedullary arteries, with a large draining vein caudally. Interposing the arterial and venous vessels was a giant venous aneurysmal dilatation located ventral to the conus medullaris and extending from L3 to T6. The patient was successfully treated by a surgical approach through a laminotomy from L3 to T11. The type IV-C spinal arteriovenous malformations or perimedullary AVFs are rare lesions predominately described at the conus medullaris with various types of angio-architecture and controversial treatment.

Usefulness of three-dimensional digital subtraction angiography in endovascular treatment of a spinal dural arteriovenous fistula

The use of 3D digital subtraction (DS) angiography provides a better understanding of spinal vascular lesion architecture. The authors report on 2 cases involving a spinal dural arteriovenous fistula (DAVF) and demonstrate the usefulness of 3D DS angiography for endovascular treatment of these spinal DAVFs. In both cases, middle-aged male patients suffered from bilateral leg hypesthesia, gait disturbance, and urinary dysfunction several months before treatment. Spinal angiography revealed DAVFs that were fed by a radicular artery branching from the intercostal artery and draining veins proceeding superiorly along the perimedullary veins. Endovascular embolization was performed in both cases. Selective 3D DS angiography of the intercostal artery clearly demonstrated the tortuous course of the feeder and the relationship among the feeding artery, fistula point, and draining veins in each case. This information was very useful in selecting a working angle for manipulating the microcatheter and for glue injection. In addition, the maximum intensity projection image from rotational DS angiography data clearly showed the fistula point at the dural sleeve and feeder entering the spinal canal via the intervertebral foramen and the relationship with the bone structure. Successful obliteration of the fistulae was achieved in both cases. Selective spinal 3D DS angiography was very useful in understanding the complex spinal vascular architecture and in choosing the best working angle and therapeutic strategy for endovascular treatment of spinal DAVFs.