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Single center experience with treatment of spinal dural arteriovenous fistulas

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Abstract

Spinal dural arteriovenous fistulas (SDAVFs) are rare pathologies with a yearly incidence of 5–10 new cases/million, constituting 60–80 % of spinal arteriovenous malformations. Clinical symptoms include progressive paraparesis, paresthesias, bladder, and bowel disturbances. The pathophysiology of SDAVFs is not well elucidated. Microneurosurgery and endovascular techniques are established treatment modalities for permanent fistula occlusion, which are oftentimes accompanied by an amelioration of neurological deficits in the long run. Here, we report our interdisciplinary neurosurgical/neuroradiological management strategy of SDAVFs in 32 patients who were evaluated retrospectively. We focused on clinical presentation, microneurosurgical and interventional technique, early, and late neurological results. Quality of life (QoL) was additionally assessed in 12 patients at last follow-up. We discuss the results against the background of the current literature. Our series and the literature indicate that clinical outcome after treatment of SDAVF is favorable in general. Both neurosurgical and neurointerventional therapies appear to be safe and effective, but short-term neurological deterioration after the intervention constitutes an as-of-yet unsolved problem. Beyond age and preoperative neurological state, presence of comorbidities had a significant influence on neurological outcome in our study sample. Self-assessed physical and mental QoL at long-term follow-up was reduced in quite a number of patients and was associated with a poorer neurological result as well as presence of comorbidities. The patients’ perspective in terms of QoL was first investigated in this study, but further research on QoL and psychosocial impairment of SDAVF patients is needed to enable individualized counseling and rehabilitation strategies.

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Disclosure

The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

Author information

Author notes

  1. Isabel Wanke

    Present address: Center of Neuroradiology, Klinik Hirslanden, Zurich, Switzerland

  2. Klaus-Peter Stein & Ibrahim Erol Sandalcioglu

    Present address: Department of Neurosurgery, Klinikum Nordtstadt, Hannover, Germany

Authors and Affiliations

  1. Department of Neurosurgery, University Hospital of Essen, Hufelandstrasse 55, 45122, Essen, Germany

    Neriman Özkan, Ilonka Kreitschmann-Andermahr, Karsten Henning Wrede, Bernadette Kleist, Klaus-Peter Stein, Oliver Gembruch, Ibrahim Erol Sandalcioglu & Ulrich Sure

  2. Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital of Essen, Essen, Germany

    Sophia Luise Goerike & Isabel Wanke

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  1. Neriman Özkan
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Correspondence to Neriman Özkan.

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Comments

Torstein R. Meling, Oslo, Norway

In this issue of NSR, Özkan et al. present their interdisciplinary neurosurgical/neuroradiological management strategy of spinal dural arteriovenous fistulas (SDAVFs) in 32 patients. The article is a retrospective clinical report. Although somewhat difficult to decipher as the table with patient characteristics is incomplete, from the text it seems that the treatments were endovascular in 5/32 (two of whom were later operated due to residual SDAVFs), microsurgical in 25/32 and another 2/32 patients of whom we only learn about due to their retreatments (endovascular and microsurgical, respectively). Follow-up was 100 % at 3 months. Outcome parameters were obliteration rates, modified Aminoff-Logue (AL) myelopathy scale and quality of life (QoL). The obliteration rates after primary therapy is not stated, but a complete fistula obliteration was eventually achieved and documented by angiography in all patients. The AL-score at the 3-month follow-up did not improve significantly (p = 0.13). Three patients (9 %) deteriorated neurologically after surgery, caused by an epidural hematoma in one and persistent intramedullary edema in two patients. With respect to clinical outcome at 3 months, 30/32 patients improved and only two (6.3 %) patients worsened neurologically after surgery. Of the 32 patients treated, only 12 patients filled in the SF-36 QoL questionnaires, making firm conclusions impossible, although the authors use a German standard population as a reference. Not surprisingly, there is a negative correlation between the AL-scores and QoL as measured by the SF-36 questionnaire, but the statistics are not shown, only the p values. The authors conclude that clinical outcome after treatment of SDAVF is good and that microneurosurgery was the treatment of choice in most cases since it provides direct access to the fistula point. It could preferably have been backed up by their own data showing that retreatment was far more frequent after endovascular than microsurgical treatment in their hands.

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Özkan, N., Kreitschmann-Andermahr, I., Goerike, S.L. et al. Single center experience with treatment of spinal dural arteriovenous fistulas. Neurosurg Rev 38, 683–692 (2015). https://doi.org/10.1007/s10143-015-0645-z

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