Spinal dural and epidural arteriovenous fistula: Recurrence rate after surgical and endovascular treatment

Abstract

IntroductionSpinal dural arteriovenous fistula consist of an heterogenous group of vascular malformation often causing severe neurological deficit due to progressive myelopathy. This type of malformation could be associated with subarachnoid or subdural hemorrhage inside the spinal canal. In the English literature surgical treatment is regarded as the best option if compared to endovascular procedure, being the latter associated with an increased risk of relapse despite its less invasiveness.MethodsIn this study a retrospective analysis of 30 patients with spinal dural and epidural fistula associated with perimedullary venous congestion was undertaken. The radiological and clinical presentation of each patient is analyzed, and the grade of myelopathy is classified through the mJOA score.ResultsA total number of 31 out of 41 collected procedures (22 surgery vs. 19 endovascular) were dural fistulas while the remaining 10 were classified as epidural. A 46% recurrence rate for endovascular treatment against 0% for surgical (p-value 0.004) was described for dural fistulas, while in the epidural fistula group the rate of recurrence was 80% and 20% respectively for endovascular and surgery treatment (p-value 0.6).DiscussionAccording to the results, surgical treatment could be considered as first-line treatment for spinal dural arteriovenous fistulas. Endovascular embolization can be proposed in selected cases, as a less invasive technique, for elderly patients or with important comorbidities. In spinal epidural arteriovenous fistulas, in view of the greater invasiveness of the surgical treatment and the non-significant difference in terms of recurrence risk between the two techniques, endovascular treatment could be proposed as a first choice treatment; in the event of a recurrence, a surgical intervention will instead be proposed in a short time.

Endovascular treatment of epidural arteriovenous fistula associated with sacral arteriovenous malformation: case report

“…Although it has been reported that epidural exposure at the actual fistula site is unnecessary and residual epidural arteriovenous shunting appears to be harmless because it does not produce venous hypertension, a surgical approach to the arterialized venous pouch is risky because the venous pouch is usually located at the ventral epidural space and may require destabilization of vertebral structures to be able to safely manage the malformation ( 5 , 7 ). So far, the optimal management strategy of SDAVFs has remained unclear ( 17 ), especially in our case, due to the fistula associated with the AVM nidus.…”

“…Therefore, as a marker for the location of the venous pouch, the pouch's position may also be connected to the symptoms. Vascular engorgement causes a significant mass effect on the nerve root in the ventral or lateral side, which can manifest as benign symptoms such as radiculopathy ( 5 , 6 ). Nevertheless, in contrast to when the venous pouch position dorsally located, the author believes that compressive symptoms are less frequently presented due to the position being farther from the nerve root.…”