Endovascular and microsurgical treatment for spinal arteriovenous malformations. Our experience
Objective – to improve the treatment quality for patients with spinal arteriovenous malformations (AVM).
Materials and methods. A retrospective analysis of endovascular and surgical treatment of patients was made. In SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» since 2005 till 2018 were operated 55 patients (34 (61.8 %) men and 21 (38.2 %) women). The age of patients ranged from 11 to 62 years (middle age is 45.3 years). The classification proposed by Anson and Spetzler in 1992 was used in order to divide patients into experimental groups: type I, arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile AVM; and type IV, perimedullary AVF. Patients with type I were 36 (65.5 %), with ІІ type – 10 (18.2 %), with ІIІ type – 5 (9.0 %), with IV type – 4 (7.3 %). For diagnostics were used MRI and spinal angiography. The Aminoff–Logue scale was used for assessment of the neurological deficiency severity. Early postoperative complications (CSF) leakage, wound infection, early postoperative worsening) were counted.
Results. 12 (21.8 %) patients were treated using the microsurgical method and 43 (78.2 %) were treated endovascular. We used endovascular and microsurgical methods to treat patients with I type spinal AVM. Microsurgical intervention for 9 (33 %) patients was performed. Complete disconnection of fistula was achieved in 9 patients. Early postoperative complication (CSF leakage) was observed in 1 (11 %) case. Endovascular treatment was performed for 27 (67 %) patients. Total disconnection was achieved in 16 (59 %) cases, 17 patients (63 %) had early transient neurological worsening. Embolization is the first-line treatment for patients with type II AVM – 8 (80 %) patients. Complete obliteration of AVM was attained in 5 patients (62.5 %), 6 (75 %) patients suffered from early worsening of postoperative neurological symptoms. The microsurgical method was used in case of low risk of spinal cord injury in 2 patients (20 %), AVMs were excluded totally in 2 patients and in 1 patient neurological deterioration was stabilized. All patients with III type AVM were treated endovascular. AVM was obliterated complete in 1 patient (20 %). Three (60 %) patients had transient neurological deterioration. Endovascular method was used to treat 3 (75 %) patients with type IV AVM. Totally disconnection of AVM was achieved in 1 (33 %) patient. Super-selective catheterization of all conductive arteries was not possible. Neurological worsening was observed in 1 (33 %) patient.
Conclusions. Angiography is the first-line diagnostic method which permits to find the most effective and safe way (endovascular or/and microsurgical treatment) to disconnect AVM from spinal cord bloodstream. Microsurgical intervention helps to achieve eye-controlled total arteriovenous disconnection. Microsurgical technique usage leads to good neurological results – neurological improvement the following day after surgery in all cases of AVM type I treatment. The structure of AVM determines effectiveness, radicality, method of treatment and the level of feeder artery catheterization. The main goal of embolization to achieve the safe catheterization level of the afferent. Multimodal treatment, which includes endovascular and microsurgical methods, is the most effective in case of AVM II and III types.
Bao YH, Ling F. Classification and therapeutic modalities of spinal vascular malformations in 80 patients. Neurosurgery. 1997 Jan;40(1):75-81. PMID:971827. https://doi.org/10.1227/00006123-199701000-00017.
Niizuma K, Endo T, Sato K, et al. Surgical treatment of spinal extradural arteriovenous fistula with parenchymal drainage: report on 5 cases. Neurosurgery. 2013 Dec;73(2 Suppl Operative):onsE287-93; discussion onsE293-4. doi: 10.1227/NEU.0000000000000189. PMID: 24077580.
Rodesch G, Hurth M, Alvarez H, et al. Embolization of spinal cord arteriovenous shunts: morphological and clinical follow-up and results – review of 69 consecutive cases. Neurosurgery. 2003 Jul;53(1):40-9; discussion 49-50. PMID: 12823872. https://doi.org/10.1227/01.NEU.0000068701.25600.A1.
Boström A, Krings T, Hans FJ, et al. Spinal glomus-type arteriovenous malformations: microsurgical treatment in 20 cases. J Neurosurg Spine. 2009 May;10(5):423-9. doi: 10.3171/2009.1.SPINE08355. PMID: 19442003.
Corkill RA, Mitsos AP, Molyneux AJ. Embolization of spinal intramedullary arteriovenous malformations using the liquid embolic agent, Onyx: a single-center experience in a series of 17 patients. J Neurosurg Spine. 2007 Nov;7(5):478-85. PMID: 17977188. doi: 10.3171/SPI-07/11/478.
Endo T, Endo H, Sato K, Matsumoto Y, Tominaga T. Surgical and endovascular treatment for spinal arteriovenous malformations. Neurol Med Chir (Tokyo). 2016 Aug 15;56(8):457-64. doi: 10.2176/nmc.ra.2015-0327. Epub 2016 Mar 4. Review. PMID: 26948701; PMCID: PMC4987445.
Anson JA, Spetzler RF. Classification of spinal arteriovenous malformations and implications for treatment. BNI Quarterly. 1992;8:2-8.
Aminoff MJ, Logue V. The prognosis of patients with spinal vascular malformations. Brain. 1974 Mar;97(1): 211-8. PMID: 4434169. doi: 10.1093/brain/97.1.211.
Krings T. Vascular malformations of the spine and spinal cord. Clin Neuroradiol. 2010 Mar;20(1):5-24. doi:10.1007/s00062-010-9036-6.
Krings T, Mull M, Gilsbach JM, Thron A. Spinal vascular malformations. Eur Radiol. 2005 Feb;15(2):267-78. Review. PMID: 15538580. DOI: 10.1007/s00330-004-2510-2.
Jellema K, Sluzewski M, van Rooij WJ, et al. Embolization of spinal dural arteriovenous fistulas: importance of occlusion of the draining vein. J Neurosurg Spine. 2005 May;2(5):580-3. PMID: 15945432. DOI: 10.3171/spi.2005.2.5.0580.
Rosenblum B, Oldfield EH, Doppman JL, Di Chiro G. Spinal arteriovenous malformations: a comparison of dural arteriovenous fistulas and intradural AVM’s in 81 patients. J Neurosurg. 1987 Dec;67(6):795-802. PMID: 3681418. DOI: 10.3171/jns.1987.67.6.0795.
Heros RC, Debrun GM, Ojemann RG, et al. Direct spinal arteriovenous fistula: a new type of spinal AVM. Case report. J Neurosurg. 1986 Jan;64(1):134-9. PMID: 3941336. DOI: 10.3171/jns.1986.64.1.0134
Krings T, Thron AK, Geibprasert S, et al. Endovascular management of spinal vascular malformations. Neurosurg Rev. 2010 Jan;33(1):1-9. doi: 10.1007/s10143-009-0204-6. Review. PMID: 19415356.
Biondi A, Merland JJ, Reizine D, et al. Embolization with particles in thoracic intramedullary arteriovenous malformations: long-term angiographic and clinical results. Radiology. 1990 Dec;177(3):651-8. PMID: 2243964. doi: 10.1148/radiology.177.3.2243964.
Spetzler RF, Zabramski JM, Flom RA. Management of juvenile spinal AVM‘s by embolization and operative excision. Case report. J Neurosurg. 1989 Apr;70(4):628-32. PubMed PMID: 2647920. DOI: 10.3171/jns.1989.70.4.0628.
Touho H, Karasawa J, Shishido H, et al. Successful excision of a juvenile-type spinal arteriovenous malformation following intraoperative embolization. Case report. J Neurosurg. 1991 Oct;75(4):647-51. PMID: 1885985. doi: 10.3171/jns.1991.75.4.0647.
Wilson DA, Abla AA, Uschold TD, et al. Multimodality treatment of conus medullaris arteriovenous malformations: 2 decades of experience with combined endovascular and microsurgical treatments. Neurosurgery. 2012 Jul;71(1):100-8. doi: 10.1227/NEU.0b013e318256c042. PMID: 22472551.
Cho KT, Lee DY, Chung CK, et al. Treatment of spinal cord perimedullary arteriovenous fistula: embolization versus surgery. Neurosurgery. 2005 Feb;56(2):232-41; Review. PMID: 15670371. doi: 10.1227/01.neu.0000147974.79671.83.
Abstract views: 136 PDF Downloads: 68