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Mamaril-Davis J, Aguilar-Salinas P, Avila MJ, Dumont T, Avery MB. Recurrence Rates Following Treatment of Spinal Vascular Malformations: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 173:e250-e297. [PMID: 36787855 DOI: 10.1016/j.wneu.2023.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Spinal vascular malformations (SVMs), including arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs), are a varied group of vascular lesions that can be subclassified according to localization, vascular structure, and hemodynamics. Early intervention is necessary to halt progression of disease and minimize irreversible dysfunction. We sought to characterize initial treatment success and recurrence rates following interventional treatment of various types of SVMs. METHODS A systematic review and meta-analysis were performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. SVMs were categorized into 4 groups: dural AVFs, perimedullary AVFs, intramedullary AVMs, and extradural-intradural AVMs (e.g., epidural, paraspinal). Initial occlusion, recurrence, and complication rates were compared using random-effects analysis. RESULTS There were 112 manuscripts included, with a total of 5626 patients with SVM. For treatment, 2735 patients underwent endovascular embolization, 2854 underwent surgical resection, and 37 underwent stereotactic radiosurgery. The initial treatment success and overall recurrence rates following surgical resection of all SVMs were 89.5% (95% CI: 80.5%-98.5%) and 2.3% (95% CI: 0.9%-3.7%), respectively. Those rates following endovascular embolization were 55.9% (95% CI: 30.3%-81.5%) and 27.7% (95% CI: 11.2%-44.2%), respectively. Higher rates of initial treatment success and lower rates of recurrence with surgery were observed in all subtypes compared to embolization. Overall complication rates were higher after embolization for each of the SVM categories. CONCLUSIONS Surgical resection of SVMs provided higher rates of initial complete occlusion and lower rates of recurrence than endovascular techniques. Attaining technical success through obliteration must still be weighed against clinical impact and natural history of the specific vascular malformation.
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Affiliation(s)
- James Mamaril-Davis
- College of Medicine, The University of Arizona College of Medicine - Tucson, Tucson, Arizona, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA
| | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA
| | - Travis Dumont
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA
| | - Michael B Avery
- Department of Neurosurgery, Banner University Medical Center / The University of Arizona, Tucson, Arizona, USA.
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Yang B, Lu T, He X, Li H. Spinal dural arteriovenous fistula: A rare but treatable disease that should not be missed by orthopedic surgeons. Front Neurol 2022; 13:938342. [PMID: 36203987 PMCID: PMC9530566 DOI: 10.3389/fneur.2022.938342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Spinal dural arteriovenous fistula (SDAVF) is a rare disease that is often misdiagnosed by orthopedic surgeons. We analyzed the reasons for the misdiagnosis and proposed countermeasures. Methods Twenty-two SDAVF patients who were initially treated in orthopedics were included. The patients were divided into a correct diagnosis group (A) and a misdiagnosis group (B). The clinical data and prognosis were evaluated. Results There were 10 patients in group A and 12 patients in group B. The clinical manifestations included limb numbness, weakness, and bladder and bowel dysfunction. Among these patients without spinal degenerative diseases which had typical magnetic resonance imaging (MRI) features in Group A were more than Group B (P < 0.05). More patients had spinal degenerative diseases in group B. In group A, seven patients were primarily diagnosed with a SDAVF after multidisciplinary teamwork (MDT). In group B, five patients were misdiagnosed with lumbar spinal stenosis, four with lumbar disc herniation, two with thoracic spinal stenosis, and one with cervical spinal stenosis and lumbar spinal stenosis and underwent cervical spinal canal and lumbar spinal canal decompression. The length of time for confirming the diagnosis was 7 months longer in group B than in group A. All patients underwent microsurgery treatment. The average follow-up duration was 11 months. The modified Aminoff-Logue Disability Scale scores showed a statistically significant difference in improvement between the two groups (P < 0.05). Conclusion when patients with dysuria especially, have intermittent spinal nerve dysfunction, the possibility of SDAVF should be considered. Awareness of the specific clinical and spinal cord edema and flow voids on MRI of a SDAVF needs to be promoted for orthopedic surgeons. Timely MDT is an important measure for reducing misdiagnosis, and steroids or inappropriate surgery should be avoided until a SDAVF is completely excluded.
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Affiliation(s)
- Baohui Yang
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Teng Lu
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xijing He
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Haopeng Li
- Department of Orthopedics, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Park KH, Jeon CH, Chung NS, Lee HD. Rapid Progression to Complete Paraplegia After Electroacupuncture in a Patient With Spinal Dural Arteriovenous Fistula: A Case Report. Front Surg 2021; 8:645884. [PMID: 34513911 PMCID: PMC8429830 DOI: 10.3389/fsurg.2021.645884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 07/30/2021] [Indexed: 11/16/2022] Open
Abstract
Spinal dural arteriovenous fistula (SDAVF) usually has an insidious clinical course, but 5–15% of the cases have acute exacerbations. In some cases, there is an abrupt progression to paraplegia following an epidural injection or anesthesia. Electroacupuncture is a form of acupuncture that applies a small electrical current to needles inserted at specific points in the body. It is widely used for its analgesic effect on back pain. In this study, we report a rare case of SDAVF in which the symptoms of a patient worsened rapidly to complete paraplegia within a few hours after applying electroacupuncture to his back. A 49-year-old man had rapid progression to complete paraplegia within a few hours of electroacupuncture on his back. MRI showed SDAVF and worsening of cord signal change. An emergency operation was performed to ligate the SDAVF. The patient was able to walk 1 month post-operatively. Most of the neurological deficits had disappeared by 1 year post-operatively, with normalization of MRI. Our case emphasizes that SDAVF patients should be careful when exposed to any circumstances that might affect the circulation around the dural arteriovenous fistula, such as electroacupuncture. Patients should also be warned in advance about the possibility of rapid exacerbation of neurological symptoms. Regardless of the severity of the neurological symptoms, immediate treatment is essential for recovery and a better outcome.
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Affiliation(s)
- Ki-Hoon Park
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Chang-Hoon Jeon
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Nam-Su Chung
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Han-Dong Lee
- Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, South Korea
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Vukić M, Barić H, Ozretić D, Jovanović I, Poljaković Z, Tudor K, Đurić KS. Spinal dural arteriovenous fistulas: a report on outcomes in a single-center retrospective cohort treated surgically and/or endovascularly. Croat Med J 2021; 62:347-352. [PMID: 34472737 PMCID: PMC8491055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/24/2021] [Indexed: 04/04/2024] Open
Abstract
AIM To report on the outcomes of spinal dural arteriovenous fistulas (sDAVFs) treatment in a single-center retrospective cohort. METHODS Data were retrieved on sDAVF cases treated surgically and endovascularly between January 2009 and January 2020. Sociodemographic, clinical, imaging data, and outcomes were analyzed. RESULTS Thirty-four patients were identified: 11 female, mean age 64.1 ± 11.5 years; mean time of symptom duration 12 (range 1-149) months. The sDAVF locations were the following: 18 (62.1%) thoracic, 4 (13.8%) lumbar, 4 (13.8%) sacral, and 3 (10%) with multiple location feeders. All patients had a motor deficit and affected walking, and the majority had a sensory deficit, bowel, and bladder dysfunction. Fifteen (44.1%) patients underwent surgical treatment, 7 (20.6%) underwent endovascular treatment, and 12 (35.3%) underwent both (crossover). Radiological myelopathy showed regression in 19 (55.9%) patients. Overall, clinical improvement (decrease in modified Rankin score) following treatment was observed in 14 patients (41.2%), worsening in 1 (2.9%), while other had unchanged status. The proportion of patients with initial treatment failure markedly differed between the before-2014 and after-2014 period. Patients who failed to improve had more extensive myelopathy. CONCLUSION Patients who underwent surgery or endovascular treatment had on average significant clinical recovery, while those who underwent treatment crossover had negligible improvement. The extent of myelopathy seems to be associated with clinical improvement.
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Affiliation(s)
| | - Hrvoje Barić
- Hrvoje Barić, Clinical Hospital Center Zagreb, Department of Neurosurgery, Kišpatićeva 12, 10 000 Zagreb, Croatia,
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Baldassarre B, Balestrino A, D'Andrea A, Anania P, Ceraudo M, Truffelli M, Melloni I, Mavilio N, Castellan L, Zona G, Fiaschi P. Management of spinal aneurysms associated with arteriovenous malformations: systematic literature review and illustrative case. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2767-2774. [PMID: 34043050 DOI: 10.1007/s00586-021-06881-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 01/29/2021] [Accepted: 05/13/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Spinal aneurysms are rare vascular malformations, commonly associated with spinal AVMs. AVM-associated spinal aneurysms are burdened by significant morbidity. The purpose of our study is to evaluate the best treatment strategy for these uncommon vascular lesions and to report an illustrative case. METHODS We reviewed clinical and radiological data of a patient surgically treated at our institution for a spinal AVM with an associated prenidal aneurysm. According to PRISMA guidelines, a systematic literature review has been performed in order to discuss the best management AVM-associated prenidal aneurysms. RESULTS In the reported case, the aneurysm showed spontaneous regression at follow-up after surgical removal of the AVM. Only 6 articles reported management of spinal prenidal AVM-associated aneurysms. Basing on our experience and data from literature, surgical treatment of the aneurysm may be indicated along with the resection of the AVM if the aneurysm is close to the nidus. Conversely, if the aneurysm is far away from the nidus or in an unfavorable position, resection of the nidus only may lead to aneurysm regression as in the reported case. CONCLUSIONS The treatment strategy for AVM-associated spinal aneurysms should be tailored on the single patient. In presence of large aneurysms that cause mass-effect symptoms, when rupture of the aneurysm is suspected or when treatment of the AVM is not proposable, direct treatment of the aneurysm should be considered. Otherwise, when complete resection of the nidus is performed, the eventually associated unruptured aneurysms located in challenging positions can be safely managed conservatively.
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Affiliation(s)
- Bianca Baldassarre
- Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Alberto Balestrino
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
| | - Alessandro D'Andrea
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Pasquale Anania
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Marco Ceraudo
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Monica Truffelli
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Ilaria Melloni
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Nicola Mavilio
- Department of Diagnostic and Interventional Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lucio Castellan
- Department of Diagnostic and Interventional Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluigi Zona
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Division of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
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Spinal Vascular Malformations: Treatment and Outcome. World Neurosurg 2019; 130:e953-e960. [PMID: 31302279 DOI: 10.1016/j.wneu.2019.07.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Vascular malformations of the spinal cord are a rare and complex clinical entity and can lead to severe morbidity with progressive spinal cord symptoms if not treated properly. In early stages, the disease is characterized by slowly progressive, nonspecific symptoms, such as gait disturbance, paresthesia, diffuse sensory symptoms, and radicular pain; in the late stages, bowel and bladder incontinence, erectile dysfunction, and urinary retention may develop. In recent decades, understanding and treatment of spinal vascular malformations have improved with the evolution of diagnostic tools and treatment modalities; however, it is still difficult to manage these cases because of the complexity of the pathology. The aims of this study were to present the long-term outcomes of our patients and to discuss the optimal management strategies. METHODS We reviewed the records of 78 patients with spinal vascular malformations and performed a retrospective, single-center case series evaluating initial occlusion, recanalization, retreatment, and neurologic status of patients with dural arteriovenous fistulas, perimedullary arteriovenous fistulas, arteriovenous malformations, and extradural arteriovenous fistulas who had undergone embolization and/or surgery. RESULTS No mortality was observed. Complete obliteration was achieved in 76 patients (97.4%). CONCLUSIONS Both endovascular and surgical treatment of spinal vascular malformations resulted in significant long-term recovery from myelopathic symptoms and improvement in quality of life for most patients.
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