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Original research
Four-dimensional digital subtraction angiography for exploration of spinal cord vascular malformations: preliminary experience
  1. Frédéric Clarençon1,2,
  2. Stéphanie Lenck2,
  3. Eimad Shotar2,
  4. Anne-Laure Boch3,
  5. Etienne Lefevre1,3,
  6. Kevin Premat1,2,
  7. Maria Del Mar Amador4,
  8. Nader-Antoine Sourour2
  1. 1 Sorbonne Université, Paris, Île-de-France, France
  2. 2 Neuroradiology, Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
  3. 3 Neurosurgery, Hôpital Universitaire Pitié-Salpêtrière, Paris, Île-de-France, France
  4. 4 Neurology, Hôpital Universitaire Pitié-Salpêtrière, Paris, Île-de-France, France
  1. Correspondence to Dr Frédéric Clarençon, Interventional Neuroradiology, Hopital Universitaire Pitie Salpetriere, Paris, Île-de-France, France; fredclare5{at}


Background The precise understanding of the angioarchitecture of spinal vascular malformations (SVMs) is often difficult to reach with conventional digital subtraction angiography (DSA). The purpose of our study was to evaluate the potential of four-dimensional DSA (4D-DSA) (Siemens Healthcare) in the exploration of SVMs.

Methods We retrospectively studied all patients who underwent spinal DSA, including 4D-DSA acquisition, from July 2018 to June 2019 at a single institution. All spinal DSA acquisitions were performed under general anesthesia. 4D-DSA acquisitions were acquired with the protocol '12 s DSA Dyna4D Neuro'. 12 mL of iodixanol 320 mg iodine/mL were injected via a 5 F catheter (1 mL/s during the 12 s 4D-DSA acquisition). Inter-rater (three independent reviewers) and intermodality agreements were assessed.

Results Nine consecutive patients (six men, three women, mean age 55.3±19.8 years) with 10 SVMs (spinal dural arteriovenous fistulas n=3, spinal epidural arteriovenous fistulas n=2, spinal pial arteriovenous fistulas n=2, and spinal arteriovenous malformations n=2; one patient had two synchronous pial fistulas) had spinal DSA, including 4D-DSA acquisition. Inter-rater agreement was good and moderate for the venous drainage pattern and the SVM subtype, respectively. In 9 of 10 cases, the quality of the acquisition was graded as good. Satisfactory concordance between 4D-DSA and the selective microcatheterization was observed in 90% of cases for the location of the shunt point.

Conclusion 4D-DSA acquisition may be helpful for a better understanding of the angioarchitecture of SVMs. Larger series are warranted to confirm these preliminary results.

  • Angiography
  • Fistula
  • Spinal cord

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  • Correction notice This article has been corrected since it was published Online First. Figure 2 was enlarged to increase readability.

  • Contributors FC: collection of the data, data analysis, and manuscript writing. SL: collection of the data, data analysis, and critical review of the manuscript. ES: critical review of the manuscript. A-LB: critical review of the manuscript. KP: collection of the data and critical review of the manuscript. EL: data analysis. MDMA: critical review of the manuscript. N-AS: critical review of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests FC reports payment for readings from Medtronic, Guerbet, Balt Extrusion, and Penumbra (not related to the study), and core lab from Codman Neurovascular and Microvention (not related to the study). N-AS is a consultant for Medtronic, Balt Extrusion, and Microvention, and has stock/stock options in Medina.

  • Patient consent for publication Not required.

  • Ethics approval The study protocol was approved by our local institutional review board (CPP Ile de France VI; HH 27_01_20). The need for patient informed consent for retrospective analyses of records and imaging data was waived by the local institutional review board. This work adheres to the World Medical Association Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data are available upon reasonable request.