Treatment strategies and results in spinal vascular malformations

We report the treatment strategies and results of 70 patients with spinal vascular malformations. Forty-six had dural arteriovenous fistulas, 12 spinal cavernous angiomas, nine intramedullary angiomas, and three intradural arteriovenous fistulas. The diagnosis was established for cavernomas by magnetic resonance images only and in the other cases by selective spinal angiography in patients whose neurological deficits, myelograms or magnetic resonance images suggested the presence of a spinal vascular malformation. All patients had symptomatic vascular malformations and were treated microsurgically. Intramedullary angiomas were operated when embolization seemed too dangerous or impossible and when they had a contact to the dorsal or lateral surface of the spinal cord. All but one were completely resected. In one angioma a small ventral residual fistula area was left. Complete obliteration of all fistulas was achieved. The cavernomas were primarily resected. Apart from one postoperative permanent deterioration with a paresis of the left arm in a patient with an intramedullary angioma, 16 cases presented only a transitory worsening of their neurological status after surgery. The long-term outcome of all these patients was good. Five patients had to be operated on again: three patients showed difficult localizations of dural fistulas which were still visible in the postoperative angiograms, one patient suffered a spinal epidural hematoma, and another patient showed a cerebrospinal fluid accumulation. We conclude that spinal dural arteriovenous fistulas, small intradural fistulas, spinal cavernomas, and symptomatic spinal angiomas with contact to the lateral or dorsal surface can be treated microsurgically with low perioperative morbidity.