Recovery from paraplegia after the treatment of spinal dural arteriovenous fistula: case report and review of the literature

Spinal dural arteriovenous fistula 8 years after lumbar discectomy surgery: A case report and review of literature

BACKGROUND

Spinal dural arteriovenous fistula (SDAVF) is an extremely rare vascular malformation of the central nervous system that is often confused with degenerative spinal disorders due to similar early symptoms and clinical features. Here, we report a case of SDAVF recurrence 8 years after lumbar spine surgery and summarize relevant literature.

CASE SUMMARY

A 54-year-old male was admitted to our hospital complaining of lower back pain, numbness in both lower extremities and intermittent claudication. Subsequent imaging identified lumbar spinal stenosis. Following surgical treatment, the patient's symptoms significantly resolved, and he was able to perform daily activities. However, similar symptoms appeared 8 years later, followed by confirmation of SDAVF diagnosis. The patient underwent neurosurgery 7 mo after symptom onset. The follow-up period lasted 14 mo, and the patient remains with marginal neurological symptoms.

CONCLUSION

This case highlights the importance of prompt SDAVF diagnosis. Due to its nonspecific clinical presentation, the clinical experience of the surgeon and definitive imaging examination are indispensable. Additionally, timely neurosurgery is effective and may significantly improve patient outcomes.

Microsurgical or endovascular strategy for complete obliteration of spinal arteriovenous shunts in a single-institute 10-year retrospective study

The objective of this retrospective study is to more fully understand the optimal strategy to manage spinal arteriovenous (AV) shunts. This study included a cohort of 35 patients with a diagnosis of spinal AV shunts who were treated over the past 10 years at a single institute. Angiographic diagnosis of intramedullary AV malformations (IM-AVM), perimedullary AV fistulas (PM-AVF), dural AV fistulas (D-AVF), or epidural AV fistulas (ED-AVF) was carefully made, and the microsurgical or endovascular strategy for them was determined at the interdisciplinary meeting consisting of neurospinal surgeons and endovascular specialists. Endovascular surgery was first considered whenever safely possible. Microscopic direct surgery using intraoperative image guidance was considered for cases in which endovascular access was challenging or not safely possible. Combined treatment was another option. The clinical condition was assessed using the modified Rankin scale (mRS). Seventeen of 35 cases were treated with microscopic direct surgery, 13 cases with endovascular surgery, and the remaining five cases with the combination. Complete angiographic obliteration was achieved in 30 of 35 cases (85.7%). Although residual AV shunts was recognized in 3 cases of IM-AVM, 1 case of PM-AVF and 1 case of ED-AVF, no angiographic recurrence was present with an average postoperative follow-up period of 44 months. The average mRS before surgery was 2.37 and significantly improved to 1.94 at the most recent follow-up. Interdisciplinary collaboration between neurospinal surgeons and endovascular specialists should be standard to achieve safe and successful outcomes in treating such rare and difficult spinal disorders.

Multidisciplinary approach in the treatment of spinal dural arteriovenous fistula-results of endovascular and surgical treatment

BACKGROUND

The results of treatment for spinal dural arteriovenous fistula (SDAVF) have been controversial. The goal of this study was to compare results of endovascular and surgical treatments to contribute to determining an optimal treatment strategy.

METHODS

A retrospective analysis of the set of 24 SDAVF patients (11 in the endovascular and 13 in the surgical group) was performed. The clinical effect (using the modified Rankin scale [mRS]), the radicality, and the number of clinical recurrences as well as the impact of age, the level of impairment, and the duration of symptoms before the treatment were evaluated.

RESULTS

The average age was 60.1 ± 8.4 years. The median duration of symptoms before establishing a diagnosis was 12 (1-70) months. Clinical improvement was reported in 11 out of 24 (45.8%) patients (36.4% following embolization and 53.8% following surgery, p = 0.444). Radical performance was achieved in 47.4% of endovascular versus 92.9% of surgical procedures (p = 0.009). Clinical recurrence was reported in 35.3% of patients in the endovascular group, whereas no clinical recurrence was reported in the surgical group (p = 0.0133). The graphical residuum after 1 surgery out of 14 (7.1%) was cured early during the control angiography. Clinical improvement was reported 42.1% of patients with mRS ≤ 3 versus 60% of patients with mRS ≥ 4 and, in 57.1% of patients aged ≥ 60 versus in 30% of patients < 60 years (p > 0.05 in both cases). The impact of the duration of symptoms on the clinical results was not statistically significant.

CONCLUSIONS

The surgical treatment of SDAVF appeared to be a more efficient method in terms of the clinical effect, radicality, and lower recurrence rate in comparison with the endovascular treatment. No statistically significant dependence of the clinical result on age, deficit burden, or symptom duration was found.

The Hybrid Assistive Limb® intervention for a postoperative patient with spinal dural arteriovenous fistula and chronic spinal cord injury: A case study

CONTEXT

The purpose of this report was to describe the improvement in walking ability using the Hybrid Assistive Limb® (HAL®) intervention in the case of a patient with paraplegia after spinal cord injury whose condition deteriorated because of a spinal dural arteriovenous fistula (SDAVF).

FINDINGS

A 48-year-old man started the HAL® intervention twice per week (total 10 sessions), after his neurologic improvement had plateaued from 3 to 6 months postoperatively for an SDAVF. During the HAL® intervention, the 10-m walk test (10MWT) without HAL® was performed before and after each session. An electromyography system was used to evaluate muscle activity of both the gluteus maximus (Gmax) and quadriceps femoris (Quad) muscles in synchronization with the Vicon motion capture system. The International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISNCSCI) motor scores of the lower extremities and the Walking Index for Spinal Cord Injury II (WISCI II) score were also assessed to evaluate motor function. The HAL® intervention improved gait speed and cadence during the 10MWT. Before the intervention, both the Gmax and left Quad muscles were not activated. After the intervention, the right Gmax and both Quad muscles were activated in stance phase rhythmically according to the gait cycle. The ISNCSCI motor score also improved from 14 to 16, and the WISCI II scored improved from 7 to 12.

CONCLUSION/CLINICAL RELEVANCE

Our experience with this patient suggests that the HAL® can be an effective tool for improving functional ambulation in patients with chronic spinal cord injury.

Rapid Recovery from Paraplegia in a Patient with Foix-Alajouanine Syndrome

BACKGROUND

Foix-Alajouanine syndrome is defined as acute neurologic deterioration in the setting of a spinal dural arteriovenous fistula.

CASE DESCRIPTION

This case report on a young patient with an unusual clinical onset of Foix-Alajouanine syndrome coincidentally occurring after his outpatient clinic appointment illustrates how prompt surgical treatment can result in rapid recovery of neurologic function despite preoperative paraplegia.

CONCLUSIONS

Venous hypertension with subsequent rapid resolution after surgical treatment is the pathophysiological mechanism underlying a dural arteriovenous fistula, in contrast to historical views suggesting that these lesions result from irreversible venous thrombosis, resulting in necrotic myelopathy.

Late diagnosis of spinal dural arteriovenous fistulas resulting in severe lower-extremity weakness: a case series

BACKGROUND CONTEXT

Spinal dural arteriovenous fistula (SDAVF) is a slow-flow extramedullary vascular lesion affecting primarily the lower thoracic and lumbar spine. The clinical sequela of these vascular changes is progressive myelopathy and severe lower-extremity weakness. Although surgical or embolic treatment of SDAVFs has improved significantly in the last years, the ambiguity of the symptoms may complicate and delay the diagnosis. The influence of the postponed diagnosis on the functional outcome of patients with SDAVF is unknown.

PURPOSE

To describe a case series of patients with SDAVF that illustrates that delayed diagnosis leads to grave neurologic and functional prognosis.

STUDY DESIGN

A case series.

METHODS

We present a series of seven patients, treated in a tertiary university rehabilitation center over 20 years. Clinical, radiologic, and functional outcomes were evaluated by retrospective chart review. Neurologic and functional evaluation at the end of rehabilitation was evaluated with the lower extremities motor score and the Aminoff-Logue scale, respectively.

RESULTS

All our patients were men with a mean age of 60.3±16 years (30-72 years), mean time until the diagnosis of SDAVF was 302.8±239 days (60-730 days), and mean overall length of stay in acute department and rehabilitation unit was 88.6±34 days (46-149 days). At the end of rehabilitation period, four patients remained at wheelchair level with an Aminoff-Logue scale grading of five whereas other functional scales showed also low levels of recovery.

CONCLUSIONS

Our series showed that the potential for functional ambulation was poor despite prolonged rehabilitation treatment in late diagnosis SDAVF. Awareness of the early symptoms of SDAVF and immediate intervention may help reduce impairment in such patients.

Intramedullary hemorrhage from a thoracolumbar dural arteriovenous fistula

BACKGROUND CONTEXT

Spinal dural arteriovenous fistulas (AVFs) are acquired lesions presenting typically with neurologic deficits secondary to chronic congestive myelopathy. The low-flow and low-volume nature of these lesions makes hemorrhage very unlikely, and intramedullary hemorrhage caused by thoracolumbar dural AVFs is exceedingly rare.

PURPOSE

The purpose of this study was to report a case of intramedullary hemorrhage caused by a thoracolumbar dural AVF.

STUDY DESIGN/SETTING

The study design included a case report and review of literature.

METHODS

A case of intramedullary hemorrhage from a thoracolumbar dural AVF was reported, and the literature regarding hemorrhagic presentations of dural AVF was reviewed.

RESULTS

A 66-year-old woman presented with a sudden onset of abdominal pain, paraplegia, sensory loss below the costal margins, and urinary retention. Magnetic resonance imaging scan showed intramedullary hemorrhage with abnormal flow voids raising suspicion of an intramedullary AV malformation. However, subsequent selective spinal angiography demonstrated a spinal dural AVF fed by the T7 intercostal artery and a varix within the draining vein. Complete obliteration of the dural AVF and the varix was achieved via embolization. As far as we are aware, there are only two other similar cases in the literature. Literature review revealed that presentation of thoracolumbar dural AVFs with hemorrhage is frequently associated with accelerated venous flow and the presence of a venous varix.

CONCLUSIONS

Although very unusual, a spinal dural AVF may present with intramedullary hemorrhage, and hemorrhage in such conditions may be associated with an accelerated venous flow and the presence of a venous varix.

Prognostic value of clinical and radiological signs in the postoperative outcome of spinal dural arteriovenous fistula

STUDY DESIGN

Retrospective consecutive case series.

OBJECTIVE

To determine predictors of outcome in patients undergoing surgical treatment of spinal dural arteriovenous fistula (SDAVF).

SUMMARY OF BACKGROUND DATA

Most previous studies assessing postoperative outcome in patients with SDAVF have been limited due to small population size, lack of sufficient information on presurgical variables, or short time of postoperative follow-up. Consequently, the most reliable predictors of functional outcome after treatment of SDAVF are not yet well established.

METHODS

Retrospective analysis of consecutive patients with SDAVF treated surgically between June 1985 and March 2008 in our institution. The Aminoff-Logue gait (G) and micturition (M) scores were used to stratify the degree of disability and the G + M score was used as the primary outcome measure. Demographics, clinical presentation, time to diagnosis, fistula level, presurgical motor and sphincter impairment, and magnetic resonance imaging findings were assessed as prognosticators for postoperative outcomes.

RESULTS

One hundred fifty-three patients were analyzed. Mean follow-up was 31 ± 36.2 months. Most patients were improved (44%) or stable (34%) upon the last follow-up. Among preoperative variables, worsening weakness with exertion was associated with a better G + M score at the last follow-up (P < 0.001) and presence of pinprick level was associated with a worse G + M score at the last follow-up (P = 0.020). On multivariable analysis, worsening weakness with exertion was associated with better outcome at the last follow-up, and higher G score at presentation and higher G + M score at discharge were associated with worse outcome at the last follow-up. Magnetic resonance images obtained postoperatively for 104 patients (mean, 19.1 ± 22.5 mo) showed complete resolution or improvement of the presurgical T2 signal abnormalities in 83.6% of cases. Changes in postoperative magnetic resonance image and fistula level did not correlate with functional outcomes.

CONCLUSION

The degree of preoperative disability from SDAFV does not determine who will benefit most from surgery and even patients with severe deficits can improve after treatment. Patients with preoperative exertional claudication and without pinprick level on examination have greater chances of postsurgical improvement.

LEVEL OF EVIDENCE

4.

Correlation between time to diagnosis and rehabilitation outcomes in patients with spinal dural arteriovenous fistula

BACKGROUND

Spinal dural arteriovenous fistulas (SDAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy although they are under diagnosed. Surgical or embolization treatment of SDAVFs improved significantly in the last decade. However, a high percentage of patients are still left with severe disability.

OBJECTIVE

To describe the correlation between time to diagnosis and the rehabilitation outcomes of eight patients with SDAVFs.

DESIGN

Retrospective chart study of all SDAVF patients in 20 years.

SETTING

A tertiary university rehabilitation center.

MAIN OUTCOME MEASURES

The lower extremities motor score (LEMS), Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM) and Walking Scale for Spinal Cord Injury (WISC II). Overall prognosis was evaluated using the Aminoff-Logue scale (ALS).

RESULTS

There were seven men and one woman with mean age of 61.3 ± 15 (30-72) and mean time until the diagnosis of SDAVF of 265.5 ± 245 days (4-730). At the end of rehabilitation period, five of the eight patients remained wheelchair dependent. Strong correlation was found between LEMS, FIM, SCIM, and WISC II scores and the functional level according to the ALS scale. A significant correlation was found between time to diagnosis and the height of the SDAVF, the clinical and rehabilitation outcomes. Patients with high SDAVF which were diagnosed late had the poorest prognosis.

CONCLUSIONS

The potential for functional ambulation in patients with SDAVF is related to the time of intervention. This finding emphasizes the important of early diagnosis and early intervention in SDAVF.

Is there a right time for surgery in paraplegic patients secondary to non traumatic spinal cord compression?

Paraplegia is a well-defined state of complete motor deficit in lower limbs, regardless of sensory involvement. The cause of paraplegia usually guides treatment, however, some controversies remain about the time and benefits for spinal cord decompression in nontraumatic paraplegic patients, especially after 48 hours of the onset of paraplegia. The objective of this study was to evaluate the benefits of spinal cord decompression in such patients. We describe three patients with paraplegia secondary to non-traumatic spinal cord compression without sensory deficits, and who were surgically treated after more than 48 hours of the onset of symptoms. All patients, even those with paraplegia during more than 48 hours, had benefits from spinal cord decompression like recovery of gait ability. The duration of paraplegia, which influences prognosis, is not a contra-indication for surgery. The preservation of sensitivity in this group of patients should be considered as a positive prognostic factor when surgery is taken into account.

Spinal arteriovenous malformation associated with spinal metameric syndrome: a treatable cause of long-term paraplegia?

Cutaneomeningospinal angiomatosis, or Cobb syndrome, is a rare metameric developmental disorder presenting as an extradural-intradural vascular malformation that involves bone, muscle, skin, spinal cord, and nerve roots. A 14-year-old girl with a red nevus involving the T6-9 dermatomes on the left side of her back presented with a 5-year history of bowel and bladder incontinence, paraplegia, and lower-extremity sensory loss. Magnetic resonance imaging demonstrated a hemangioma in the T-8 and T-9 vertebral bodies and a spinal cord AVM nidus extending from T-6 to T-9. The AVM was successfully embolized and the patient regained lower-extremity strength, ambulation, and normal sphincter functions after 5 years of having been wheelchair bound. The authors report the restoration of ambulation after endovascular embolization of a large spinal AVM in a patient with long-standing paraplegia due to Cobb syndrome.

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.