Krings T, Mull M, Reinges M H T, Thron A
Department of Neuroradiology, University Hospital of the University of Technology, Aachen, Pauwelsstrasse 30, 52057 Aachen, Germany.
Neuroradiology. 2004 Mar;46(3):238-42. doi: 10.1007/s00234-003-1147-1. Epub 2004 Feb 4.
Spinal dural arteriovenous fistula (SDAVF) is the most common spinal vascular malformation. It mainly affects men after the fifth decade and is usually an acquired lesion with an unknown etiology. We report on a patient with the unusual finding of two separate SDAVFs at the level of L1 on the right and L2 on the left side. Initial selective spinal digital subtraction angiography (DSA) was terminated with demonstration of a SDAVF at the level of L1 but incomplete demonstration of all segmental arteries. Due to a recurrent deterioration of the patient's neurological status, and persistent pathological vessels seen on MRI, a second spinal DSA was performed 6 years later, demonstrating the second fistula at the level of L2 on the left side with a separate venous drainage pattern. A retrospective analysis of the angiographic films suggested that both fistulas had already been present 6 years previously. This conclusion is justified because of a transient and faint opacification of the left L2 fistula demonstrated on the films after injection of the right L2 segmental artery. We conclude that in the case of incomplete angiography and persistent clinical and MR findings not only reopening of the treated SDAVF has to be taken into account but also the existence of a second fistula. Since this is the first case of a double fistula in our series of 129 SDAVFs, and given the few reported cases of double SDAVFs, we do not think that completion of selective spinal DSA has to be postulated routinely after a fistula has been found. However, repeat angiography should be performed in patients who continue to deteriorate, fail to improve with persisting MRI pathologies, or demonstrate delayed deterioration after a period of improvement.
脊髓硬脊膜动静脉瘘（SDAVF）是最常见的脊髓血管畸形。它主要影响50岁以后的男性，通常是一种病因不明的后天性病变。我们报告了一例患者，其在右侧L1和左侧L2水平发现了两个独立的SDAVF，这一发现并不常见。最初的选择性脊髓数字减影血管造影（DSA）在显示L1水平的一个SDAVF时终止，但所有节段动脉未完全显示。由于患者神经功能状态反复恶化，且MRI上可见持续的异常血管，6年后进行了第二次脊髓DSA，显示左侧L2水平有第二个瘘，且有独立的静脉引流模式。对血管造影胶片的回顾性分析表明，两个瘘在6年前就已存在。这一结论是合理的，因为在注射右侧L2节段动脉后，胶片上显示左侧L2瘘有短暂且微弱的造影剂充盈。我们得出结论，在血管造影不完全且临床和MRI表现持续存在的情况下，不仅要考虑已治疗的SDAVF复发，还要考虑是否存在第二个瘘。由于这是我们129例SDAVF系列中的首例双瘘病例，且双SDAVF的报道病例较少，我们认为在发现一个瘘后，不必常规要求完成选择性脊髓DSA。然而，对于病情持续恶化、MRI病变持续存在但无改善或在病情改善一段时间后出现延迟恶化的患者，应进行重复血管造影。
