Clinical and Radiologic Characteristics of Deep Lumbosacral Dural Arteriovenous Fistulas

Abstract

Background and purpose: Spinal dural arteriovenous fistulas located in the deep lumbosacral region are rare and the most difficult to diagnose among spinal dural arteriovenous fistulas located elsewhere in the spinal dura. Specific clinical and radiologic features of these fistulas are still inadequately reported and are the subject of this study.

Materials and methods: We retrospectively evaluated all data of patients with spinal dural arteriovenous fistulas treated and/or diagnosed in our institution between 1990 and 2017. Twenty patients with deep lumbosacral spinal dural arteriovenous fistulas were included in this study.

Results: The most common neurologic findings at the time of admission were paraparesis (85%), sphincter dysfunction (70%), and sensory disturbances (20%). Medullary T2 hyperintensity and contrast enhancement were present in most cases. The filum vein and/or lumbar veins were dilated in 19/20 (95%) patients. Time-resolved contrast-enhanced dynamic MRA indicated a spinal dural arteriovenous fistula at or below the L5 vertebral level in 7/8 (88%) patients who received time-resolved contrast-enhanced dynamic MRA before DSA. A bilateral arterial supply of the fistula was detected via DSA in 5 (25%) patients.

Conclusions: Clinical symptoms caused by deep lumbosacral spinal dural arteriovenous fistulas are comparable with those of spinal dural arteriovenous fistulas at other locations. Medullary congestion in association with an enlargement of the filum vein or other lumbar radicular veins is a characteristic finding in these patients. Spinal time-resolved contrast-enhanced dynamic MRA facilitates the detection of the drainage vein and helps to localize deep lumbosacral-located fistulas with a high sensitivity before DSA. Definite detection of these fistulas remains challenging and requires sufficient visualization of the fistula-supplying arteries and draining veins by conventional spinal angiography.

FIGURE.

A and B, Sagittal T2- and contrast-enhanced T1-weighted images reveal congestive myelopathy and dilated perimedullary veins (white arrows). C and D, Spinal CE-MRA shows dilated radicular veins in the lumbar region suspicious for an SDAVF in the lumbosacral region (white arrows). E–H, DSA examinations identify the fistula in the dural sleeve of the left S2 root (black arrowhead) supplied via the lateral sacral artery (white arrowhead). Note the upward draining sacral radicular vein (black arrow). I and J, Intraoperative indocyanine green angiography confirms the intradural course of the arterialized draining vein (black arrow) embedded at the ventral side of the S2 nerve root.