Brain Advance Access originally published online on August 18, 2006
Brain 2006 129(12):3150-3164; doi:10.1093/brain/awl220
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Review Article |
Spinal dural arteriovenous fistulas: a congestive myelopathy that initially mimics a peripheral nerve disorder
1 Department of Neurology St Elisabeth Hospital Tilburg, Tilburg 2 Department of Neurology, University Medical Center Utrecht Utrecht, The Netherlands
Correspondence to: K. Jellema, St Elisabeth Hospital, PO Box 90151, 5000 LC Tilburg, The Netherlands E-mail: K.Jellema{at}elisabeth.nl
Spinal dural arteriovenous fistula (SDAVF) is a rare and enigmatic disease entity. The clinical features and structural changes have been recognized since 1926, and the pathophysiology and the essentials of treatment since 1974, but up to the present day it is unknown why these fistulas develop. The fistula between a radicular artery and the corresponding radicular vein within the dural root sleeve leads to congestion of the venous outflow of the spinal cord and eventually ischaemia. Patients, who are mostly middle-aged men, develop a progressive myelopathy, which at the early stages of the disease often mimics a polyradiculopathy or anterior horn cell disorder. By the time involvement of upper motoneurons or sacral segments makes the diagnosis of SDAVF inescapable, patients suffer from considerable neurological deficits. The diagnosis relies on MRI, which shows swelling of the spinal cord, with a centrally located hyperintense signal on T2-weighted images, and with hypointense ‘flow void’ phenomena dorsal to the cord, representing enlarged and tortuous veins. Catheter angiography is required to determine the exact location of the fistula as well as the angio-architecture, on which the mode of treatment depends. If the arterial feeder of the fistula is a tributary of the anterior spinal artery, embolization is not possible. After embolization recanalization may occur, but this is rarely seen after filling of the draining vein with glue. Alternatively, operation is a safe and permanent mode of treatment. No prognostic factors have been reliably established. Muscle strength and gait disturbances respond better to treatment than pain and symptoms related to damage of sacral segments. In any middle aged male patient with ascending motor or sensory deficits in the legs, SDAVF should be considered in order to prevent irreversible handicap.
Key Words: spinal dural arteriovenous fistulas; clinical features; treatment; review
Abbreviations: AVMs, arteriovenous malformations; SDAVF, spinal dural arteriovenous fistula
Received February 21, 2006. Revised July 4, 2006. Accepted July 18, 2006.
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