Aghakhani Nozar, Parker Fabrice, David Philippe, Lasjaunias Pierre, Tadie Marc
Department of Neurosurgery, Bicêtre University Hospital, Le Kremlin-Bicetre, France.
Stroke. 2008 Oct;39(10):2756-9. doi: 10.1161/STROKEAHA.108.517037. Epub 2008 Jul 17.
The rarity of spinal dural arteriovenous fistulae makes physicians often overlook this potential diagnosis in patients with progressive gait disturbance and paraparesis. Consequently, patients with spinal dural arteriovenous fistulae can gradually become completely paraplegic if the final diagnosis is delayed considerably. The objective of the current study is to demonstrate that, particularly in patients with paraplegia, surgical treatment of fistula is necessary and often has a favorable outcome.
Of 42 patients with spinal dural arteriovenous fistulae treated in our institution (surgery or endovascular treatment), 6 were paraplegic preoperatively (Grade IV on the McCormick scale and Grade V on the Aminoff scale, Grade 5 of modified Rankin Scale with motor ASIA between 0 and 10 for both lower limbs). Their clinical history revealed that paraplegia appeared progressively within a period of <3 months. All patients were clinically evaluated at 6 weeks, 6 months, and then annually during an average follow-up of 3 years. Patients received at least one spinal angiography and MRI test during the follow-up period.
Total exclusion of the fistula was performed surgically in all cases and was confirmed by spinal angiography. No surgical complications were recorded. All patients improved postoperatively. Three patients showed almost normal walking (Grade I on the McCormick scale, I on the Aminoff scale, Grade 1 of modified Rankin Scale) and 3 were able to walk with a cane (Grade II on McCormick, Grade III on Aminoff scale, Grade 2 of modified Rankin Scale). MRI tests were normal in all patients.
Our results indicate that treatment of fistula is a necessary intervention, even in patients with complete paraplegia.
脊髓硬脊膜动静脉瘘较为罕见，这使得医生在面对进行性步态障碍和双下肢轻瘫患者时，常常忽略这一潜在诊断。因此，如果最终诊断被大幅延迟，脊髓硬脊膜动静脉瘘患者可能会逐渐发展为完全性截瘫。本研究的目的是证明，尤其是对于截瘫患者，瘘管的手术治疗是必要的，且通常会取得良好的效果。
在我们机构接受治疗的42例脊髓硬脊膜动静脉瘘患者（手术或血管内治疗）中，6例术前为截瘫（麦考密克量表IV级，阿明诺夫量表V级，改良Rankin量表5级，双下肢运动亚洲脊髓损伤量表评分在0至10分之间）。他们的临床病史显示，截瘫在不到3个月的时间内逐渐出现。所有患者在6周、6个月时进行临床评估，随后在平均3年的随访期间每年评估一次。患者在随访期间至少接受一次脊髓血管造影和MRI检查。
所有病例均通过手术完全排除瘘管，并经脊髓血管造影证实。未记录到手术并发症。所有患者术后均有改善。3例患者行走几乎正常（麦考密克量表I级，阿明诺夫量表I级，改良Rankin量表1级），3例患者能够拄拐行走（麦考密克量表II级，阿明诺夫量表III级，改良Rankin量表2级）。所有患者的MRI检查均正常。
我们的结果表明，即使对于完全性截瘫患者，瘘管治疗也是必要的干预措施。
