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Treatment of spinal dural arteriovenous
malformations a single center experience Andres
RH, Guzman R, Remonda L, Schroth G, Widmer HR,
Seiler RW and Barth A
Departments of Neurosurgery and
Neuroradiology University Hospital, Berne,
Switzerland
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Spinal dural arteriovenous fistulas (Type I
spinal AVMs)

• Most common type of spinal vascular
  malformations (80)
• Rare and often misdiagnosed entities
• Natural history progressive myelopathy
• 50 of untreated patients disabled within 3 years
• Goal of treatment definitive occlusion of the
  fistula
• Optimal treatment strategy has yet to be defined

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Anatomy and pathophysiology

• AVM located in the dura of the nerve root and/or
  adjacent spinal dura
• Feeder radicular artery
• Drainage medullary vein -gt retrograde filling of
  the coronal vein plexus
• Congestion and dilatation of the venous plexus
• Venous hypertension -gt reduced perfusion,
  ischemia, edema

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Treatment strategies
Surgical treatment hemilaminectomy and occlusion
of the fistula Endovascular treatment catheter
embolization Combined treatment strategy

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Spinal angiography
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Surgical anatomy
Fistula point
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Surgical technique
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Study design
12 patients with spinal dural fistulas treated in
our institution from 1994 to 2004 9 men, 3
women Median age 59.18 years Location of the
fistula thoracic n8, lumbar n3, sacral n1

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Modified Aminoff-Logue grading scale
Grade Gait
0 Normal
1 Leg weakness, abnormal gait or stance, but no restriction of activity
2 Restricted activity
3 Requiring 1 stick for walking
4 Requiring 2 sticks, crutches, or walker
5 Confined to wheelchair
Grade Micturation
0 Normal
1 Hesitancy, frequency, urgency
2 Occasional urinary incontinence or retention
3 Total incontinence or persistent retention

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Results
Patient Age, Sex Localization Treatment ALS pre ALS post Outcome
1 67, M Th 6 Surgical 6 2
2 67, M Th 6 Endovascular (2x) 2 5 -
3 57, M Th 5 Combined 3 1
4 68, M L 1 Endovascular 6 4
5 59, M Th 6 Surgical 3 1
6 76, F L 2 Endovascular 6 4
7 57, F L 1 Combined 2 1
8 20, M Th 9 Endovascular (2x) 2 1
9 74, M Th 8 Combined 6 7 -
10 45, M Th 8 Endovascular 3 2
11 76, M Th 7 Surgical 6 2
12 51, F S 2 Endovascular 2 2 -
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Results
Group n n (OC ) n (OC -)
Surgical 3 3 0
Endovascular 6 4 2
Combined 3 2 1

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Conclusions
Both endovasular and surgical treatment of spinal
dural AVFs resulted in occlusion of the fistula
and in a good and lasting clinical outcome in the
majority of cases. For successful surgical
occlusion, interruption of the venous drainage on
the intradural side of the fistula is
mandatory. In specific situations, a combined
neurosurgical and endovascular approach is
required to achieve complete occlusion of the
AVF. Embolization should be attempted at the
time of diagnostic angiography if the lesion is
endovascularly accessible.