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Standard of practice: embolization of spinal arteriovenous fistulae, spinal arteriovenous malformations, and tumors of the spinal axis
  1. Sandra Narayanan1,
  2. Robert W Hurst2,
  3. Todd A Abruzzo3,
  4. Felipe C Albuquerque4,
  5. Kristine A Blackham5,
  6. Ketan R Bulsara6,
  7. Colin P Derdeyn7,
  8. Chirag D Gandhi8,
  9. Joshua A Hirsch9,
  10. Daniel P Hsu10,
  11. Muhammad Shazam Hussain11,
  12. Mahesh V Jayaraman12,
  13. Philip M Meyers13,
  14. Athos Patsalides14,
  15. Charles J Prestigiacomo15
  1. 1Department of Neurosurgery and Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
  2. 2Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3Department of Radiology, University of Cincinnati, Cincinnati, Ohio, USA
  4. 4Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
  5. 5University Hospitals Department of Radiology, Case Western Reserve University, Cleveland, Ohio, USA
  6. 6Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
  7. 7Department of Radiology, Washington University, St Louis, Missouri, USA
  8. 8Neurological Institute of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
  9. 9Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
  10. 10Interventional Neuroradiology, University Hospitals-Case Medical Center, Cleveland, Ohio, USA
  11. 11Cleveland Clinic Stroke Program, Cleveland Clinic, Cleveland, Ohio, USA
  12. 12Warren Alpert School of Medical at Brown University, Providence, Rhode Island, USA
  13. 13Department of Radiology and Neurological Surgery, Columbia University, New York, USA
  14. 14Department of Neurological Surgery, New York Presbyterian Hospital, Weill Cornell Medical College New York, New York, USA
  15. 15Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA
  1. Correspondence to Dr S Narayanan, Department of Neurosurgery and Neurology, Wayne State University/Detroit Medical Center, 4160 John R, #930, Detroit, MI 48201, USA; snarayanan{at}

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Spinal vascular malformations include a heterogeneous group of pathological/anatomical entities with congenital and acquired etiologies that induce spinal cord dysfunction, primarily through intradural extramedullary drainage and enlargement of the coronal venous plexus, resulting in venous hypertension and/or a direct mass effect. These lesions are rare, comprising approximately 5% of neurovascular disorders. Clinical manifestations are pain or venous congestive myelopathy, usually in the thoracolumbar spine. This may progress to hemorrhage from vascular thrombosis and necrotizing myelopathy (Foix–Alajouanine syndrome).1 Due to the differing hemodynamics, pathophysiology, and treatment considerations, a thorough knowledge of the various types of spinal dural arteriovenous fistulas (dAVFs) and arteriovenous malformations (AVMs) is essential.


The first descriptions of the single coiled dural vessel form of spinal dAVF with intradural extramedullary venous drainage were published by Kendall and Logue in 1977.2 Type I spinal dAVFs (also known as angioma racemosum venosum) are the most common and comprise 56% of all spinal lesions in the spinal vascular malformation database at the University of Toronto.3 They occur nearly 3–4 times as frequently in men. These generally low flow lesions may be further divided into type I-A (single feeder dAVFs) and I-B (≥2 arterial feeders).4 Although they are typically supplied via radicular arteries, anterior spinal artery feeders have also been reported.5 Type II spinal AVMs (also known as angioma racemosum arteriovenosum) are characterized by a compact, glomus-type, totally intramedullary nidus. They have no gender predominance but are symptomatic in younger patients. Type III (juvenile or metameric) spinal AVMs are highly complex intramedullary lesions that frequently extend into the extramedullary, epidural, or even extraspinal compartments. Vascular supply includes radiculo-medullary, radiculo-pial, radiculo-meningeal, and segmental arteries. They are fortunately quite rare.

Type IV (perimedullary) spinal AVFs are intradural extramedullary lesions, usually on the pial surface of the cord or filum terminale. They are divided into three groups based on their flow: single feeder, low flow (type IV-A); moderate flow with ≥1 feeders (type IV-B); and very high flow, multiple feeders (type IV-C). Type IV-C dAVFs are supplied by the anterior and occasionally posterior spinal arteries.6

Although the majority of spinal vascular malformations can be classified into one of the above categories, purely extradural vascular lesions have been described.7–10 Intraspinal cavernous malformations are discrete intramedullary lesions comprised of low flow, thin walled sinusoids without intervening normal parenchyma. Approximately 3–5%11 of cavernous malformations occur in the spinal cord, usually in the thoracic and cervical cord.12 As cavernous malformations are angiographically occult, treatment of these lesions is outside the scope of this report.


MRI has replaced myelography as the firstline imaging modality for a suspected spinal dAVF3 due to its utility in demonstrating anterior/posterior nidal components with respect to cord anatomy and revealing epidural, vertebral, paraspinal, and muscular tissue involvement in metameric AVMs. A high quality diagnostic spinal angiogram with thin focal spot to identify the artery of Adamkiewicz, locate all arterial feeders/draining veins, any intra- and para-nidal components such as aneurysms, fistulas, and venous ectasias, and identify the subtype of AVM/dAVF is crucial. The fistula site is often remote from the draining veins, which can extend over several segments. Prolonged mean transit time in the spinal cord (ie, >20 s) is consistent with venous congestion. Provocative testing with amytal sodium and/or lidocaine with simultaneous neurophysiological monitoring for motor/somatosensory evoked potentials may increase the safety of embolization, particularly when rapid flow in a pedicle pre-embolization obscures clear visualization of all of the distal branches.13

Endovascular treatment

Endovascular treatment of spinal AVMs largely consists of superselective injection of permanent liquid embolic agents, which at present consists of n-butyl cyanoacrylate (Codman Neurovascular, Raynham, Massachusetts, USA) and Onyx liquid embolic agent (ev3, Irvine, California, USA). Particle embolization is not recommended and is viewed as palliative, necessitating multiple treatments for even that goal due to inevitable revascularization14 ,15 and recruitment of smaller, less accessible feeders. Although the initial goal is parent artery occlusion, the endovascular treatment goal should include nidal penetration and, in the case of a type I or IV dAVF, penetration of the draining vein to obliterate the fistula and eliminate the possibility of recruiting new feeders.16 Cure of complex epidural AVMs17 with excellent recovery18 has been reported with Onyx. Treatment of juvenile spinal AVMs is largely palliative due to nidal size, intramedullary infiltration, intricate vascular supply and drainage, and steadily progressive neurological morbidity associated with these lesions. When embolizing high flow AVF components of a metameric AVM, use of ‘coil nests’ for occlusion of distal arterial feeders may minimize unwanted venous embolization of liquid embolic agents.

The majority of patients experience some clinical improvement on closure of the fistula19 although the rapidity and extent of improvement directly correlates with the initial duration of symptoms and degree of disability.20 Spectacular improvement, such as reversal of paraplegia, is occasionally seen.21 Motor function responds first, followed by sensation, and bowel/bladder incontinence is the last to demonstrate improvement. Patients with an angiographic cure who experience clinical deterioration likely have venous thrombosis with an increased mass effect on the cord. For this reason, some practitioners utilize a heparin infusion for 24–48 h following trans-arterial embolization, particularly when venous outflow restriction is present.16

Spinal dAVFs


The presence of a spinal dAVF is an indication for treatment in most patients. Careful consideration of the natural history of spinal dAVFs in elderly patients or those with significant medical comorbidities may bear out a higher benefit:risk ratio for conservative management in these individuals. Embolization may be contraindicated in those patients in whom the anterior spinal artery originates from the same pedicle as the dAVF.


The indicators of efficacy of endovascular management are technical and clinical success. Technical success is defined as occlusion of the target draining vein, definitively or adjunctively; the extent to which this goal is met should be clearly documented in the procedural report. Clinical success may be defined as obliteration of the vascular malformation in conjunction with improvement or stabilization of symptoms.

Perimedullary AVFs


The presence of a perimedullary AVF, even if clinically silent, is an indication for treatment. Embolization is indicated if sufficiently superselective catheterization can be performed; surgery may be the best therapeutic modality in cases of type IA dAVF.

Spinal AVMs


Indications for embolization of spinal cord AVMs include all symptomatic patients with curable lesions; adjuvant therapy prior to surgery/radiosurgery; palliative therapy when total obliteration is not practical, and the patient suffers from progressive neurologic deficit or is at high risk of hemorrhage (associated aneurysm, pseudoaneurysm, AVF, venous ectasia, outflow restriction, or previous hemorrhage).


Technical success is defined as occlusion of the target feeding arteries, cure of steal phenomena, resolution of intravertebral venous hypertension, and preservation of the draining veins.

Extradural vascular malformations


Indications for embolization include adjunctive (preoperative) and/or palliative treatment when the patient suffers from neurological symptoms.

Spinal axis tumor embolization


The indications for embolizing hypervascular spinal tumors include decreasing surgical morbidity by reduction of blood loss, shortening operative time, increasing the likelihood of a complete resection, relieving intractable pain or spinal obstruction,22 reducing expected tumor recurrence, stabilization of function, and sole treatment for a patient who is a poor candidate for surgical, radiation, and/or chemotherapies.

Hypervascular tumor types for which embolization may be suitable include benign tumors (hemangiomas, aneurysmal bone cysts, osteoid osteomas, osteoblastomas, chondromas), malignant tumors (giant cell tumors, chordomas, osteogenic sarcomas, chondrosarcomas, hemangiopericytomas, lymphomas, multiple myelomas, plasmacytomas), metastatic tumors (renal cell carcinoma,23 thyroid carcinoma, and others), and primary spinal cord tumors (hemangioblastomas).24

When >5% of the procedures are performed for indications other than those listed above, a review should be conducted.


The indicators of efficacy of endovascular management are technical and clinical success. Technical success is defined as occlusion of the target vessels. Clinical success is defined as a decrease in expected blood loss during surgery in conjunction with palliation of symptoms.


An internal review should be conducted whenever a new and unexpected major deficit (eg, paralysis) or death occurs.


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  • Contributors Each author made a substantial contribution to the concept and content of this standards document.

  • Competing interests None.

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