TREATMENT OF GIANT INTRADURAL (PERIMEDULLARY) ARTERIOVENOUS-FISTULAS

TEN PATIENTS WITH giant intradural spinal arteriovenous fistulas (peri medullary Types II and III) were treated with embolization alone (thre e patients) or in combination with surgery (seven patients). Their age s at the time of treatment ranged from 2 to 40 years, with a mean of 1 9.5 years. The indications for treatment included progressive myelopat hy in five patients, spinal subarachnoid hemorrhage in four, and acute paraplegia in one. Associated conditions included Rendu-Osler-Weber s yndrome in two patients, and Cobb's syndrome in two patients. In one p atient, the cause of the fistula may have been related to epidural ane sthesia traumatizing a low tethered cord. Angiographically, the fistul as were subclassified in three groups: a single-hole fistula supplied by a single feeding medullary artery (three patients); a single-hole f istula supplied by multiple medullary arteries (three patients); and m ultiple separate fistulas supplied by multiple medullary arteries (fou r patients). Eight patients were classified as perimedullary Type III and two as perimedullary Type II. Embolic agents were delivered from t ransarterial routes in 14 procedures and transvenous routes in 2 proce dures. A total of 16 embolizations and 8 operations were performed in 10 patients. Seven patients were cured of their fistula (as demonstrat ed by angiography), two patients had 5% residual filling and are sched uled for future therapy. One refused a follow-up angiographic examinat ion. Complications related to embolization included rupture of the ant erior spinal artery by a detachable balloon, resulting in transient wo rsening of paraplegia with recovery to baseline. Transient worsening o f symptoms after surgery was common, but all patients returned to base line or better. Dramatic improvement was observed in four patients. Th e follow-up period ranged from 3 to 112 months, with a mean of 44.8 mo nths. Giant (perimedullary) intradural arteriovenous fistulas can be e ffectively managed with endovascular and/or surgical techniques.