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Multi-detector-row CT angiography as a preoperative evaluation for spinal arteriovenous fistulae

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Abstract

The role of multi-detector-row computed tomographic angiography (MDCTA) in spinal vascular malformations has not yet been determined. We present a report on a short series of spinal arteriovenous fistulae (AVF) evaluated by MDCTA. With 4-row and 16-row MDCTA, three cases of spinal dural AVF and one case of perimedullary AVF were examined. Each case was also examined by magnetic resonance (MR) imaging and spinal catheter angiography. In two patients with spinal dural AVF, including one patient with angiographically occult AVF, MDCTA successfully located the site of the AVF in a multi-planar reformation image. MDCTA failed to locate the remaining case of spinal dural AVF, probably due to the small amount of shunting blood volume at the fistula. In a patient with perimedullary AVF, MDCTA visualized the broad range of the lesion, including the anterior spinal artery as a single feeder, the fistulous point, and the single perimedullary draining vein. In conclusion, although conventional spinal angiography might be still essential, MDCTA provides useful information for the surgeon in treatment of the spinal dural AVF. Further accumulation of clinical cases is required to determine the potential of MDCTA for perimedullary AVF. MDCTA should be considered as a choice of investigation in the evaluation of spinal AVFs.

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Authors and Affiliations

  1. Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan

    Satoshi Yamaguchi, Kuniki Eguchi, Yoshihiro Kiura, Masaaki Takeda & Kaoru Kurisu

  2. Department of Neurosurgery, Kagoshima University Graduate School of Medicine, Kagoshima, Japan

    Tetsuya Nagayama, Hiroyuki Uchida & Kazunori Arita

  3. Department of Neurosurgery, National Hospital Organization, Kure Medical Center, Hiroshima, Japan

    Yoko Ito & Takuhiro Hotta

Authors
  1. Satoshi Yamaguchi
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  2. Kuniki Eguchi
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  3. Yoshihiro Kiura
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  4. Masaaki Takeda
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  5. Tetsuya Nagayama
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  6. Hiroyuki Uchida
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  7. Yoko Ito
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  8. Takuhiro Hotta
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  9. Kazunori Arita
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  10. Kaoru Kurisu
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Correspondence to Satoshi Yamaguchi.

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Comments

Ludwig Benes, Marburg, Germany

Yamaguchi and co-workers have interestingly detailed their first experience of multi-detector-row CT angiography (MDCTA) for the preoperative examination of patients suffering from spinal arteriovenous fistulae. Since the demonstration of the artery of Adamkiewicz by multi-detector-row helical CT by Takase et al. in 2002 [1], it is a logically consistent idea to identify dural AV fistulae with this modern technique. Although the patient number is limited (n = 4), the authors add a valuable diagnostic tool for dural and perimedullary AV fistulae apart from spinal DSA and MRI angiography. Spinal dural and perimedullary AV fistulae are rare diseases, and the prospective evaluation of MDCTA in comparison with the diagnostic standards will be a very challenging task for the future. Until then, conventional spinal DSA should be kept as the gold standard diagnostic feature for these vascular abnormalities.

Reference

1. Takase K, Sawamura Y, Igarashi K, Chiba Y, Haga K, Saito H, Takahashi S (2002) Demonstration of the artery of Adamkiewicz at multi-detector row helical CT. Radiology 223(1):39–45

Timo Krings, Aachen, Germany

Spinal vascular malformations are rare and still under-diagnosed entities which, if not treated properly, can lead to considerable morbidity, with progressive spinal cord symptoms. Depending on the type of vascular malformation, initial symptoms may vary between acute onset of neurological deficits due to intramedullary or subarachnoidal haemorrhages and subacute onset due to venous congestion leading to progressive myelopathy. While the latter pathomechanism leads to non-specific initial neurological symptoms that can make an early diagnosis difficult, the former leads to acute manifestations of spinal vascular malformations that are typically diagnosed early in the course of the disease. For the diagnosis, classification and subsequent treatment of these rare entities, spinal super-selective digital subtraction angiography is necessary. Since this technique is technically demanding, especially in elderly patients, non-invasive methods to diagnose the pathological shunt and to locate the height of the feeding arteries are of great interest. These techniques require a high spatial and temporal resolution and a large field of view, since arteries of the spine and spinal cord are small in calibre, difficult to distinguish from their venous counterparts and variable in location. The very interesting article by Yamaguchi et al. describes four patients in whom CT angiography was performed to locate the fistula. This technique is promising, and further research, especially in a larger group of patients, has to be done; however, some potential shortcomings have to be stressed as well: the field of view necessary to scan for spinal dural AV fistulae is large (in fact these pathological shunts may be encountered from the foramen magnum to the sacral region), therefore, the amount of radiation is considerable, the bolus timing difficult and potential breathing artefacts may degrade image quality. Likewise, an early (i.e. arterial) demonstration of venous structures may be difficult to achieve with a prolonged intravenous bolus. Since arteriovenous transit time is approximately 10 s in the spine, a clear separation between the arterial phase and the venous phase may be difficult to achieve, resulting in non-visualization of the great radiculomedullary artery. Whether or not this artery is arising from the same segmental artery as the shunting artery is an important piece of information, which is why we always perform super-selective spinal angiography prior to a therapeutic intervention. Still, many of these described shortcomings will be solved with further evolution of scanner hardware and software. In this regard, the present article can be seen as a “proof of principle” of a new and emerging technology that will be of help for the physician treating patients with spinal vascular malformations.

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Yamaguchi, S., Eguchi, K., Kiura, Y. et al. Multi-detector-row CT angiography as a preoperative evaluation for spinal arteriovenous fistulae. Neurosurg Rev 30, 321–327 (2007). https://doi.org/10.1007/s10143-007-0088-2

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  • DOI: https://doi.org/10.1007/s10143-007-0088-2

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