Keisuke Takai1, Toshiki Endo2, Takao Yasuhara3, Toshitaka Seki4, Kei Watanabe5, Yuki Tanaka5, Ryu Kurokawa6, Hideaki Kanaya6, Fumiaki Honda7, Takashi Itabashi8, Osamu Ishikawa9, Hidetoshi Murata10, Takahiro Tanaka10, Yusuke Nishimura11, Kaoru Eguchi11, Toshihiro Takami12, Yusuke Watanabe12, Takeo Nishida13, Masafumi Hiramatsu3, Tatsuya Ohtonari14, Satoshi Yamaguchi15, Takafumi Mitsuhara15, Seishi Matsui16, Hisaaki Uchikado17, Gohsuke Hattori17, Nobutaka Horie18, Hitoshi Yamahata19, Makoto Taniguchi1. 1. 8Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo. 2. 2Department of Neurosurgery, Kohnan Hospital, Sendai. 3. 13Department of Neurosurgery, Okayama University Graduate School of Medicine, Okayama. 4. 1Department of Neurosurgery, Hokkaido University Hospital, Sapporo. 5. 3Department of Orthopaedic Surgery, Niigata University Medical and Dental Hospital, Niigata. 6. 4Department of Neurosurgery, Dokkyo Medical University Hospital, Tochigi. 7. 5Department of Neurosurgery, Gunma University Hospital, Gunma. 8. 6Department of Orthopaedic Surgery, Japanese Red Cross Narita Hospital, Chiba. 9. 7Department of Neurosurgery, The University of Tokyo Hospital, Tokyo. 10. 9Department of Neurosurgery, Yokohama City University Hospital, Yokohama. 11. 10Department of Neurosurgery, Nagoya University Hospital, Nagoya. 12. 11Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka. 13. 12Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka. 14. 14Department of Spinal Surgery, Brain Attack Center, Ota Memorial Hospital, Hiroshima. 15. 15Department of Neurosurgery, Hiroshima University Hospital, Hiroshima. 16. 16Department of Neurosurgery, Ehime University Hospital, Ehime. 17. 17Department of Neurosurgery, Kurume University Hospital, Fukuoka. 18. 18Department of Neurosurgery, Nagasaki University Hospital, Nagasaki; and. 19. 19Department of Neurosurgery, Kagoshima University Hospital, Kagoshima, Japan.
Abstract
OBJECTIVE: Spinal arteriovenous shunts are rare vascular lesions and are classified into 4 types (types I-IV). Due to rapid advances in neuroimaging, spinal epidural AVFs (edAVFs), which are similar to type I spinal dural AVFs (dAVFs), have recently been increasingly reported. These 2 entities have several important differences that influence the treatment strategy selected. The purposes of the present study were to compare angiographic and clinical differences between edAVFs and dAVFs and to provide treatment strategies for edAVFs based on a multicenter cohort. METHODS: A total of 280 consecutive patients with thoracic and lumbosacral spinal dural arteriovenous fistulas (dAVFs) and edAVFs with intradural venous drainage were collected from 19 centers. After angiographic and clinical comparisons, the treatment failure rate by procedure, risk factors for treatment failure, and neurological outcomes were statistically analyzed in edAVF cases. RESULTS: Final diagnoses after an angiographic review included 199 dAVFs and 81 edAVFs. At individual centers, 29 patients (36%) with edAVFs were misdiagnosed with dAVFs. Spinal edAVFs were commonly fed by multiple feeding arteries (54%) shunted into a single or multiple intradural vein(s) (91% and 9%) through a dilated epidural venous plexus. Preoperative modified Rankin Scale (mRS) and Aminoff-Logue gait and micturition grades were worse in patients with edAVFs than in those with dAVFs. Among the microsurgical (n = 42), endovascular (n = 36), and combined (n = 3) treatment groups of edAVFs, the treatment failure rate was significantly higher in the index endovascular treatment group (7.5%, 31%, and 0%, respectively). Endovascular treatment was found to be associated with significantly higher odds of initial treatment failure (OR 5.72, 95% CI 1.45-22.6). In edAVFs, the independent risk factor for treatment failure after microsurgery was the number of intradural draining veins (OR 17.9, 95% CI 1.56-207), while that for treatment failure after the endovascular treatment was the number of feeders (OR 4.11, 95% CI 1.23-13.8). Postoperatively, mRS score and Aminoff-Logue gait and micturition grades significantly improved in edAVFs with a median follow-up of 31 months. CONCLUSIONS: Spinal epidural AVFs with intradural venous drainage are a distinct entity and may be classified as type V spinal vascular malformations. Based on the largest multicenter cohort, this study showed that primary microsurgery was superior to endovascular treatment for initial treatment success in patients with spinal edAVFs.
OBJECTIVE:Spinal arteriovenous shunts are rare vascular lesions and are classified into 4 types (types I-IV). Due to rapid advances in neuroimaging, spinal epidural AVFs (edAVFs), which are similar to type I spinal dural AVFs (dAVFs), have recently been increasingly reported. These 2 entities have several important differences that influence the treatment strategy selected. The purposes of the present study were to compare angiographic and clinical differences between edAVFs and dAVFs and to provide treatment strategies for edAVFs based on a multicenter cohort. METHODS: A total of 280 consecutive patients with thoracic and lumbosacral spinal dural arteriovenous fistulas (dAVFs) and edAVFs with intradural venous drainage were collected from 19 centers. After angiographic and clinical comparisons, the treatment failure rate by procedure, risk factors for treatment failure, and neurological outcomes were statistically analyzed in edAVF cases. RESULTS: Final diagnoses after an angiographic review included 199 dAVFs and 81 edAVFs. At individual centers, 29 patients (36%) with edAVFs were misdiagnosed with dAVFs. Spinal edAVFs were commonly fed by multiple feeding arteries (54%) shunted into a single or multiple intradural vein(s) (91% and 9%) through a dilated epidural venous plexus. Preoperative modified Rankin Scale (mRS) and Aminoff-Logue gait and micturition grades were worse in patients with edAVFs than in those with dAVFs. Among the microsurgical (n = 42), endovascular (n = 36), and combined (n = 3) treatment groups of edAVFs, the treatment failure rate was significantly higher in the index endovascular treatment group (7.5%, 31%, and 0%, respectively). Endovascular treatment was found to be associated with significantly higher odds of initial treatment failure (OR 5.72, 95% CI 1.45-22.6). In edAVFs, the independent risk factor for treatment failure after microsurgery was the number of intradural draining veins (OR 17.9, 95% CI 1.56-207), while that for treatment failure after the endovascular treatment was the number of feeders (OR 4.11, 95% CI 1.23-13.8). Postoperatively, mRS score and Aminoff-Logue gait and micturition grades significantly improved in edAVFs with a median follow-up of 31 months. CONCLUSIONS:Spinal epidural AVFs with intradural venous drainage are a distinct entity and may be classified as type V spinal vascular malformations. Based on the largest multicenter cohort, this study showed that primary microsurgery was superior to endovascular treatment for initial treatment success in patients with spinal edAVFs.
Authors: Mohammed A Azab; Emma R Dioso; Matthew C Findlay; Jayson Nelson; Cameron A Rawanduzy; Philip Johansen; Brandon Lucke-Wold Journal: J Rare Dis Orphan Drugs Date: 2022-06-07