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Endovascular management of spinal vascular malformations

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Abstract

Spinal vascular malformations are rare diseases with a wide variety of neurological presentations. In this article, arteriovenous malformations (both from the fistulous and glomerular type) and spinal dural arteriovenous fistulae are described and an overview about their imaging features on magnetic resonance imaging (MRI) and digital subtraction angiography is given. Clinical differential diagnoses, the neurological symptomatology and the potential therapeutic approaches of these diseases which vary depending on the underlying pathology are given. Although MRI constitutes the diagnostic modality of first choice in suspected spinal vascular malformation, a definite diagnosis of the disease and therefore the choice of suited therapeutic approach rests on selective spinal angiography. Treatment in symptomatic patients offers an improvement in the prognosis. In most spinal vascular malformations, the endovascular approach is the method of first choice; in selected cases, a combined or surgical therapy may be considered.

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Authors and Affiliations

  1. Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada

    Timo Krings & Ronit Agid

  2. Department of Neuroradiology, University Hospital Aachen, Aachen, Germany

    Timo Krings & Armin K. Thron

  3. Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital de Bicetre, Le Kremlin-Bicetre, Paris, France

    Timo Krings, Sasikhan Geibprasert & Pierre L. Lasjaunias

  4. The Department of Diagnostic Radiology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

    Sasikhan Geibprasert

  5. The Department of Neurosurgery, University Hospital Aachen, Aachen, Germany

    Franz J. Hans & Marcus H. T. Reinges

  6. UHN Division of Neuroradiology, University of Toronto, Toronto Western Hospital, 399 Bathurst St., 3MCL-429, Toronto, Ontario, M5T 2S8, Canada

    Timo Krings

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  1. Timo Krings
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Correspondence to Timo Krings.

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Comments

Helmuth Steinmetz, Frankfurt/Main, Germany

Krings et al. provide a nice overview of the nosology, imaging findings and treatment options of the main types of spinal dural or intra-dural arteriovenous malformations (AVM), i.e. spinal dural fistulas, on the one hand, and medullary AVMs of the fistulous or glomerular type on the other. Obviously, the relatively low numbers of patients and interventions even in specialised centres renders this field difficult for firm differential therapeutic recommendations, not unlike the situation presently encountered in cerebral AVMs. Nevertheless, the particularly experienced neuroradiological authors from three countries plausibly point out that, based on the available literature and personal experience, open neurosurgery will usually be the treatment of first choice in dural fistulas, whereas a primary endovascular approach may promise more success in most cases of medullary AVMs. Different from the management of cerebral AVMs, radiotherapy rarely appears to be an option. The article gives a profound overview over a complex topic. It demonstrates that similar to many other neurovascular disorders the management of spinal AVMs certainly requires an interdisciplinary approach in specialised neurovascular centres.

Anton Valavanis, Zurich, Switzerland

In this comprehensive review, the authors summarise their experience with the endovascular management of spinal arteriovenous malformations along with relevant and useful data from the literature.

It combines the experience from two centres, which made significant contributions to (1) the understanding of the complex vascularisation, (2) the elaboration of a useful classification system and (3) the endovascular treatment of spinal vascular malformations.

The necessity to obliterate the initial segment of the draining vein of dural AVFs and the selection between complete or partially targeted embolisation of pial AVMs or AVFs are key concepts guiding the endovascular management of spinal AVMs.

Concerning the clinical outcome of technically successful embolisation of spinal dural AVFs, in the commentator’s experience, this depends mainly on the time interval between the appearance of the first clinical manifestation and the therapeutic intervention.

The authors are to be congratulated for this useful review of a complex and rare subject.

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Krings, T., Thron, A.K., Geibprasert, S. et al. Endovascular management of spinal vascular malformations. Neurosurg Rev 33, 1–9 (2010). https://doi.org/10.1007/s10143-009-0204-6

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  • DOI: https://doi.org/10.1007/s10143-009-0204-6

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