Spinal Dural Arteriovenous Fistula Case Review & Treatment Pathway Coordination

• Date and pattern of symptom onset.
• Progressive, stepwise, fluctuating or acute deterioration.
• Leg weakness, gait distance, falls and walking aids.
• Sensory symptoms, sensory level, pain and proprioceptive loss.
• Spasticity, reflex changes and muscle wasting.
• Urinary, bowel and sexual-function history.
• Previous periods of temporary improvement or worsening.
• Current transfers, self-care, employment and independence.

• Original DICOM files and formal reports.
• Sagittal and axial T1- and T2-weighted sequences.
• Thoracic, lumbar and conus imaging; cervical or whole-spine imaging where indicated.
• Contrast-enhanced sequences.
• Longitudinal intramedullary T2 hyperintensity and cord expansion.
• Perimedullary flow voids or enhancing vessels.
• Conus, cauda and dorsal cord-surface findings.
• Earlier MRI studies for comparison.

Degenerative disease may coexist and should not automatically be assumed to explain the myelopathy when cord oedema and abnormal perimedullary vessels are present.

• Dynamic MRA source images and reconstructions.
• Suspected fistula level and side.
• Early venous filling and cranial or caudal venous drainage.
• Relationship between the predicted level and later DSA findings.
• Technical limitations and field of coverage.

Time-resolved MRA can help localize a fistula and plan angiography but does not automatically replace complete spinal DSA.

• Full dynamic runs from all relevant segmental injections.
• Documented cervical, intercostal, lumbar and sacral territories as appropriate.
• Fistula level and side.
• Radiculomeningeal feeding artery.
• Intradural draining vein and perimedullary venous pattern.
• Cranial and caudal venous drainage.
• Anterior spinal artery and critical radiculomedullary artery origins.
• Technical limitations, non-selective injections or incomplete territories.

• Date, centre and operator report.
• List of arteries and levels actually catheterized.
• Whether complete venous phases were recorded.
• Technical difficulties, vessel occlusion or access limitations.
• MRI or MRA findings that remained suspicious.
• Whether images were independently re-reviewed.

A negative examination does not reliably exclude SDAVF when the angiographic study was incomplete or the clinical and MRI pattern remains strongly suggestive.

• CSF studies and inflammatory or infectious testing.
• Brain MRI and neurological review.
• EMG or nerve-conduction studies.
• Degenerative spinal imaging and previous decompression surgery.
• Corticosteroid, immunotherapy or other treatment history.
• Clinical response or deterioration after treatment.
• Alternative diagnoses that were considered and why they remain uncertain.

• Procedure report and angiographic images.
• Target feeder and microcatheter position.
• Embolic material used.
• Whether embolic material crossed the fistula into the proximal draining vein.
• Immediate angiographic result.
• Spinal arterial or neurological complications.
• Follow-up DSA and residual or recurrent shunt.

• Operative level, side and exposure.
• Identification of the arterialized draining vein.
• Temporary clipping, ICG or other intraoperative vascular imaging.
• Neurophysiological monitoring where used.
• Method of coagulation and disconnection.
• Immediate postoperative neurological examination.
• Control DSA or other confirmation of closure.
• Residual fistula, wrong-level exposure or retreatment history.

• Urinary urgency, retention, catheterization and incontinence.
• Bowel control and constipation.
• Sexual-function symptoms where relevant.
• Urology or urodynamic assessment where performed.
• Physical and occupational therapy reports.
• Walking video, aid use, transfers and endurance.
• Spasticity, neuropathic pain and pressure-injury risk.

• Antiplatelet and anticoagulant medication.
• Kidney function and contrast allergy.
• Bleeding or clotting disorders.
• Previous anaesthetic complications.
• Access to local spinal neurosurgery, neurointervention, rehabilitation and emergency MRI.
• Ability to complete control angiography and long-term follow-up.
• Family or caregiver support and travel fitness.

SDAVF usually involves a dural shunt near a nerve root with intradural venous drainage. Intramedullary spinal AVMs and perimedullary arteriovenous fistulas have different shunt locations, arterial supply, flow patterns, haemorrhagic presentations and treatment strategies. These diagnoses should not be combined under one generic “spinal vascular malformation” treatment pathway.

The typical course is progressive or stepwise weakness, sensory change, gait impairment and later sphincter dysfunction. Symptoms can fluctuate with exertion or posture and may initially appear non-specific. A slow course should not be interpreted as benign because prolonged venous hypertension can produce irreversible spinal-cord injury.

Conus oedema and urinary, bowel or sexual dysfunction are common in advanced disease even when the fistula is located at another spinal level. Sphincter recovery is less predictable than motor improvement. Documentation should distinguish urgency, retention, overflow, incontinence and baseline urological disease.

Spinal-cord oedema and abnormal veins can extend over many levels. The fistula may lie well above or below the most abnormal cord signal. Angiography should therefore not be limited to a single level based only on symptoms or MRI oedema.

Longitudinal T2 signal change and enhancement can resemble inflammatory myelitis. Perimedullary vessels, conus involvement, older age and progressive myelopathy should trigger vascular review. Acute deterioration after corticosteroid treatment has been reported in unrecognized SDAVF, but medication decisions remain with the treating physicians.

Lumbar or cervical stenosis is common in the age group affected by SDAVF and can distract from the vascular diagnosis. Degenerative findings should be matched carefully to the neurological level and cord-imaging pattern. Previous decompression without expected improvement should prompt reconsideration of the diagnosis.

Time-resolved or 4D-MRA can improve pre-angiographic localization and reduce unnecessary catheterization. It can miss or mislocalize a lesion and does not show every critical spinal artery reliably. Definitive treatment planning still commonly requires complete spinal DSA.

Spinal angiography is technically demanding and should document all relevant segmental territories and complete venous phases. A negative study is only as reliable as its coverage and image quality. The review should confirm whether the anterior spinal artery and major radiculomedullary supply were identified before treatment.

Surgery usually targets the arterialized intradural draining vein rather than removing the extensive venous network. A limited exposure may permit direct identification and disconnection. Risks include neurological injury, CSF leak, infection, wrong-level exposure and incomplete interruption. Intraoperative vascular imaging can support but does not replace postoperative confirmation where uncertainty remains.

Endovascular treatment can be definitive only when the embolic agent reaches the shunt and proximal intradural draining vein safely. Proximal feeder occlusion alone may lead to persistent or recurrent shunting and can make later access more difficult. The relationship to normal radiculomedullary arteries is central to procedural safety.

Microsurgery has generally shown higher durable occlusion and lower recurrence in retrospective series, while embolization may offer a less invasive route in favourable anatomy. The choice depends on feeder anatomy, access, shared spinal arterial supply, treatment experience and patient condition rather than a universal rule.

Gait, pain or cord oedema can improve despite residual shunting, and early recovery may be incomplete despite successful disconnection. Treatment success should be based on appropriate vascular confirmation and elimination of pathological venous drainage—not symptoms or MRI change alone.

Persistent shunting may follow incomplete embolic penetration, wrong-level surgery, failure to disconnect the draining vein or an unrecognized additional fistula. New deterioration after initial improvement warrants renewed MRI and vascular review. Retreatment may involve repeat embolization, surgery or both.

Most cases involve a single thoracolumbar fistula, but multiple, cervical, sacral or intracranial sources with spinal venous drainage can occur. An atypical clinical or angiographic pattern should not be forced into the common thoracolumbar model.

Although the usual course is gradual, patients can worsen rapidly. Acute weakness, sphincter change or severe pain requires urgent reassessment for worsening venous infarction, haemorrhage, compression, infection or a treatment complication. A known fistula does not exclude another emergency cause.

Motor function and walking may improve over months, while sensory loss, neuropathic pain and sphincter dysfunction often recover less completely. Earlier diagnosis and better pre-treatment function are generally associated with better outcomes. The main treatment goal may be arrest of further decline rather than full restoration.

Rehabilitation may address gait, transfers, endurance, spasticity, pain, bladder, bowel and return to daily activity. Severe immobility can create pressure-injury, thrombosis, deconditioning and caregiver risks. Rehabilitation should begin without obscuring the need for definitive fistula closure.

Meaningful outcomes include confirmed fistula closure, halted neurological decline, walking, independence, pain, sensation and sphincter function. Follow-up should define when repeat MRI or angiography is required and who is responsible for rehabilitation and local neurological care.