Treatment of spinal cord perimedullary arteriovenous fistula: embolization versus surgery

To provide the optimal treatment strategy for perimedullary arteriovenous fistula (PMAVF).

Nineteen patients with PMAVF (Type IVa in 9 patients, Type IVb in 6, and Type IVc in 4) were treated at Seoul National University Hospital between January 1988 and March 2001. Their mean age was 28 years (range, 6-52 yr), and the male-to-female ratio was 1.7:1. The mean follow-up period was 20 months (range, 2-55 mo). Most patients presented with symptoms of slowly progressive myelopathy (13 patients). On spinal angiography, all but 2 showed fistula at the level of the conus medullaris. The feeder was the anterior spinal artery and/or the posterior spinal artery in 14 patients and the posterior spinal artery in 5. All patients underwent endovascular or surgical treatment.

With endovascular treatment (11 patients; IVa, n = 5; IVb, n = 2; IVc, n = 4), complete angiographic obliteration of fistula was performed in 5 and partial obliteration in 4 (IVa, n = 1; IVb, n = 2; IVc, n = 1). Symptomatic improvement or arrest of progression was achieved in 5 of 9 patients with complete or partial occlusion. Embolization failed in two (IVa, n = 1; IVc, n = 1). With surgery (10 patients [IVa, n = 6; IVb, n = 4], including 2 patients with partial or failed embolization), most (9 of 10) were improved or stable.

Good results were achieved with surgery for Types IVa and IVb PMAVF located at the level of the conus medullaris. For Type IVc PMAVF, a fistula located on the ventral side of the spinal cord or above the conus medullaris, endovascular treatment might be considered. Because of rapidly evolving endovascular techniques, however, further studies are warranted.