J Neurosurg Spine 8:462–467, 2008

Usefulness of three-dimensional digital subtraction
angiography in endovascular treatment of a spinal
dural arteriovenous fistula
Report of 2 cases
NORIAKI MATSUBARA, M.D., SHIGERU MIYACHI, M.D., TAKASHI IZUMI, M.D.,
TOMOTAKA OHSHIMA, M.D., ARIHITO TSURUMI, M.D., OSAMU HOSOSHIMA, M.D.,
TAKESHI KINKORI, M.D., AND JUN YOSHIDA, M.D.
Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan

PThe use of 3D digital subtraction (DS) angiography provides a better understanding of spinal vascular lesion architecture. The authors report on 2 cases involving a spinal dural arteriovenous fistula (DAVF) and demonstrate the usefulness of 3D DS angiography for endovascular treatment of these spinal DAVFs. In both cases, middle-aged malepatients suffered from bilateral leg hypesthesia, gait disturbance, and urinary dysfunction several months before treatment. Spinal angiography revealed DAVFs that were fed by a radicular artery branching from the intercostal artery anddraining veins proceeding superiorly along the perimedullary veins. Endovascular embolization was performed in bothcases. Selective 3D DS angiography of the intercostal artery clearly demonstrated the tortuous course of the feeder andthe relationship among the feeding artery, fistula point, and draining veins in each case. This information was very useful in selecting a working angle for manipulating the microcatheter and for glue injection. In addition, the maximum
intensity projection image from rotational DS angiography data clearly showed the fistula point at the dural sleeve andfeeder entering the spinal canal via the intervertebral foramen and the relationship with the bone structure. Successful
obliteration of the fistulae was achieved in both cases. Selective spinal 3D DS angiography was very useful in understanding the complex spinal vascular architecture and in choosing the best working angle and therapeutic strategy forendovascular treatment of spinal DAVFs. (DOI: 10.3171/SPI/2008/8/5/462)
KEY WORDS • endovascular embolization • spinal angiography •spinal dural arteriovenous fistula • 3D digital subtraction angiography

C

URRENTLY, 3D rotational angiography has undergone

widespread use. Rotational angiography is performed using the C-arm, which rotates around thepatient’s head in a few seconds. The rotational data are automatically transferred to a workstation, and this information allows us to obtain 3D DS angiography images a few
minutes after rotational angiography. The 3D DS angiography images provide a better understanding of vessel architecture and vascular lesions. Many reports have underscored the usefulness of 3D DS angiography for intracranial
vascular lesions, especially in the treatment of cerebral
aneurysms;1–3,5–7,12 however, there have been few reports of
the use of this methodology for other vascular disease–relat-

Abbreviations used in this paper: AVF = arteriovenous fistula;
CT = computed tomography; DAVF = dural AVF; DS = digital subtraction; MIP = maximum intensity projection; MR = magnetic resonance; NBCA = N-butyl-cyanoacrylate.

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ed issues, including spinal vascular lesions. In this paper, we
report 2 cases of spinal DAVFs and demonstrate the usefulness of 3D DS angiography for spinal vascular lesions.
Case Reports
Case 1
History and Examination. This 60-year-old male patientwith a 1-year history of bilateral leg hypesthesia presented
with gait disturbance and urinary hesitation 3 months before treatment. Spinal T2-weighted MR imaging showed
an intramedullary high-intensity signal change and swelling on the spinal cord at T7–10 and a low-intensity signal
on the dorsal side of the spinal cord indicating a flow void.
Spinal angiography revealed a DAVF fed by the radicularartery branching from the left T-10 intercostal artery and adraining vein proceeding superiorly along the perimedullary veins. The artery of Adamkiewicz was detected by a
J. Neurosurg.: Spine / Volume 8 / May 2008

Digital subtraction angiography for spinal DAVF
left T-9 intercostal artery angiogram and had no relationship with the DAVF.
Operation and Postoperative Course. We chose to perform endovascular embolization in this patient, because the
DAVF was supplied by only a single feeding artery and acomplete resolution was expected. The embolization was
performed after local anesthesia was induced in the patient.
A 4-Fr sheath was introduced from the right common femoral artery. The intercostal artery at T-10 underwent catheterization using a 4-Fr shepherd’s hook–shaped catheter.
Rotational angiography was performed using the Axiom Artis dBA system (Siemens AG). The rotational angle
was . 200° and the rotational speed of the C-arm was
40°/second. Rotational data were acquired in a 960 3 960
matrix using a field-of-view 12-inch flat-panel detector.
The data were then sent to the workstation (syngo X-Workplace, Siemens AG), which automatically produced a 3D
DS angiography image, MIP image, and so on. The contrast material used in these cases was 300 mgI/ml of nonionic contrast medium. The rotational angiogram at T-10
was obtained using an injection delay of 0.5 seconds and an
injection rate of 0.7 ml/second, for a contrast medium total
volume of 4.1 ml.
Although the DAVF was difficult to understand in detailusing conventional spinal angiography, selective 3D DS
angiography at T-10 clearly demonstrated the tortuouscourse of the feeder and the relationship among the feedingartery, fistula point, and draining veins (Fig. 1A and B). In

addition, using the MIP images provided by rotational angiography data, we confirmed that the fistula point was
located at the dural sleeve and confirmed its relationshipwith the surrounding architecture (the spinal canal, spinal
cord, and vertebral body; Fig. 1C–E).
By manually rotating the 3D DS angiography image in aworkstation, a precise working angle for manipulating a
microcatheter and injecting glue was chosen based on thisrotated image (Fig. 2A and B). Because the radicular arterybranched off from the intercostal artery at a sharp angle inthis case, the ventral branch was embolized using detachable coils in advance. The microcatheter was then manipulated to turn with the coil mass and guided into the target
feeding artery (Fig. 2C). After provocative testing, 0.36 mlof 25% NBCA mixed with lipiodol was injected into thefistula using the microcatheter. This solution penetrated thedrainage veins well, and successful obliteration of the fistula was achieved (Fig. 2D–G).
Postoperatively, the patient’s paraparesis disappearedalmost completely on the following day, and other symptoms such as urinary dysfunction and dysesthesia gradually improved. Although some high-intensity signal changeof the spinal cord on T2-weighted MR imaging has remained, the abnormal flow void completely disappeared.
Case 2
History and Examination. This 50-year-old male patient
initially presented with a 2-month history of bilateral leg

FIG. 1. Case 1. Three-dimensional DS angiography images (A and B) and MIP images (C–E) obtained from rotational
angiography data showing the relationship between bone and vascular structures. The nonsubtraction (A) and subtraction(B) 3D DS angiography images demonstrate the tortuous course of the feeding artery and the relationship among the feeding artery, fistula point, and draining veins. In the 3 MIP images, the coronal image (C) shows the fistula point, which
was clearly detected at the dural sleeve (arrow); the sagittal image (D) shows lesions on the dorsal side of the spinal cord;
and the axial image (E) shows the feeding artery entering the spinal canal via the intervertebral foramen (arrow).

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N. Matsubara et al.

FIG. 2. Case 1. Images of the catheterization procedure. A: Selective T-10 3D DS angiography image of the working angle for catheterization clearly demonstrates the radicular artery sharply branching off from the intercostal artery.
B: Schematic illustration of the vascular architecture in the patient showing the left T-10 intercostal artery (1), ventral
branch (2), dorsal branch (3), radicular artery (4), posterior vertebral branch (5), fistula point (6), and draining vein (7).
C: Left T-4 intercostal angiogram showing the microcatheter tip navigated into the radicular artery (double arrow) after
coil embolization of the ventral branch (arrow). D: Selective T-10 3D DS angiography image of the working angle used
for NBCA injection. E: Superselective angiogram, of a similar view as in panel D, from the working angle. The fistula point was clearly visualized (arrow). F: Angiogram showing injection of NBCA. The injection of NBCA penetrated into the draining vein (arrowheads). G: This T-10 angiogram obtained after embolization shows complete obliteration of the fistula.

hypesthesia and gait disturbance. Several days before treatment, however, his bilateral paraplegia and urinary dysfunction rapidly deteriorated.
Spinal T2-weighted MR imaging showed marked edemaon the spinal cord at T1–L1 and flow void signal, whichwere similar to the results in Case 1. Spinal angiography
revealed a DAVF fed by radicular arteries branching fromthe right T-6 (main feeder) and T-5 intercostal arteries. Avery small artery of Adamkiewicz was detected on a rightT-10 angiogram in this patient and had no relationship with
the DAVF.
Operation and Postoperative Course. The deterioration of
the patient’s symptoms was so rapid that emergency endovascular embolization was performed. The intervention
was performed after local anesthesia was administered tothe patient. A 4-Fr sheath was introduced from the rightcommon femoral artery and the T-6 intercostal artery firstunderwent catheterization using a 4-Fr cobra-shaped catheter.
Using the same angiography system as in Case 1, a rotational T-6 angiogram was obtained with an injection
delay of 0.8 seconds at an injection rate of 1.0 ml/second,464

for a contrast medium total volume of 6.0 ml. The precise
working angle for catheterization and glue injection wasdetermined using the manually rotated 3D DS angiography
images from a workstation. A microcatheter was easily
guided into the target feeding artery and the fistula was embolized with 0.4 ml of 25% NBCA (Figs. 3 and 4). Subsequently, the feeding artery from the T-5 intercostal arterywas embolized using NBCA in the same manner, and total
fistula obliteration was achieved. Postoperatively, the patient’s symptoms, particularly paraplegia, were rapidly improved on the day following the operation.
Discussion
The understanding and classification of spinal cord vascular malformations and DAVFs have rapidly advancedwith the development of sophisticated diagnostic equipment such as angiography and MR imaging apparatus.9 The
main treatment method for these conditions has been direct
operation, but the demand for using endovascular techniques has been increasing because it is a less invasive
treatment option. For successful endovascular embolizaJ. Neurosurg.: Spine / Volume 8 / May 2008

Digital subtraction angiography for spinal DAVF

FIG. 3. Case 2. Three-dimensional DS angiography images (A and B) and MIP images (C–E) obtained from rotational
angiography data. A and B: Selective nonsubtraction (A) and subtraction (B) T-6 3D DS angiography images show the
relationship between bone and vascular structures similar to Case 1. C–E: Coronal (C), sagittal (D), and axial (E) MIP
images of the DAVF obtained from the rotational DS angiography images. The fistula point is also clearly detected at
the dural sleeve (arrow) as it was in Case 1.

tion, it is important that a microcatheter is selectively guided into the feeder branching off from the radicular artery as
distally as possible, and a liquid material (such as NBCA)
should be carefully injected to penetrate from the fistulapoint to the draining vein.13,17 For a spinal DAVF with a single or small number of feeders, as in these cases, there is ahigh possibility for a complete resolution using endovascular embolization alone.
Three-dimensional DS angiography clearly provides better comprehension of the 3D complex vessel architecture.
Despite many reports of the usefulness of 3D DS angiography for intracranial vascular lesions, especially in connection with cerebral aneurysm embolization,1–3,5–7,12 only 3
studies provide an evaluation of this imaging procedure asapplied to spinal vascular lesions.8,14,15
Two case reports presented the usefulness of 3D DS angiography in the treatment of spinal hemangioblastoma.8,15
Kern and colleagues8 indicated the usefulness of spinal
3D DS angiography for preoperative examination and surgical planning for a thoracic spinal nerve hemangioblastoma. Sciubba and associates15 also reported the use of 3D
DS angiography in 2 cases of cervical spinal cord hemangioblastoma. Prestigiacomo et al.14 disclosed 17 selective
spinal 3D DS angiograms acquired in 14 cases of spinal
arteriovenous malformation, AVF and DAVF. These investigators concluded that selective spinal 3D DS angiography
is an excellent adjunct to conventional DS angiography,
providing clinicians better information about the relationJ. Neurosurg.: Spine / Volume 8 / May 2008

ships among the feeding arteries, nidus, aneurysm, draining
vein, and bone structure; helping to discriminate between
intramedullary or perimedullary lesions; and for selecting
the precise working angle for catheterization and treatment,
and therefore assisting in treatment strategy decisions. In
addition, use of 3D DS angiography reduces the total radiation dose that is necessary.14
In our 2 cases, the relationships between the DAVF andthe bone structure were confirmed by using 3D reconstruction images (subtraction and nonsubtraction) and MIP images together. This information served to pinpoint the fistula location on the dural sleeve, as well as the feeders
entering the spinal canal via the intervertebral foramen anddraining veins running along the dorsal side of the spinal
cord. In addition, manually rotated 3D DS angiography images on the workstation were very helpful in selecting thebest working angle from which to sufficiently identify afeeder of the radicular artery branching off from the intercostal artery, fistula point, and draining vein.
Depiction of the 3D structure of the spinal vascular lesion and fistula identification may be possible in 3D CT
angiography,10,18,19 and is especially useful when the bone
structure is involved. The image resolution of 3D CT
angiography, however, is inferior to that provided by selective 3D DS angiography, because contrast medium is notinjected selectively into an intercostal artery. Also, improper timing from the injection of contrast medium until filming may result in mixing of the arterial and venous phases
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N. Matsubara et al.

FIG. 4. Case 2. Images of the catheterization procedure. A: A selective T-6 3D DS angiography image of the working angle used for catheterization and NBCA injection. B: Selective T-6 angiogram of a similar view to panel A. C:
Schematic illustration of the vascular architecture in the patient showing the left T-6 intercostal artery (1), ventral branch(2), dorsal branch (3), radicular artery (4), posterior vertebral branch (5), fistula point (6), and draining vein (7). D: Angiogram of the feeding artery from the working angle. The fistula point is clearly visualized (arrow). E: Angiogram
showing the injection of NBCA, which penetrated into the draining vein (arrows). F: This T-6 angiogram after embolization shows no filling of the fistula.

and thus result in a poor image. A problem can also occur
when subtracting the surrounding structure and reconstructing the 3D CT angiography image if some type of
artifact reaches an adjacent vascular structure in a narrowspinal canal.
Magnetic resonance angiography has also become an
option for these lesions. The latest MR imaging technology may depict spinal cord vascular lesions in 3D using contrast medium or 3D image-processing software.4,11,16,19 Useof MR angiography has a disadvantage, however, because
it cannot provide a sufficiently precise image to determine
the relationship of the lesion with surrounding bone structure. An additional drawback of using MR angiography isthat an artifact due to body movement and thoracic motion
synchronized with breathing can easily adversely affect theimage. Thus, the imaging resolution provided by spinal
MR angiography is generally not sufficient for endovascular treatment.
Conventional spinal angiography is essential for evaluation of spinal vascular disease, but it is also adversely
affected by motion artifacts due to heartbeat, breathing, orbowel peristalsis. General anesthesia and administration of
glucagons are available to correct these problems, but there
are limitations to the use of these corrections. Conventional
angiography provides only 2D imaging, but selective 3DDS angiography provides optimal 3D vascular images. A
flat-panel detector can obtain more exact data with rota466

tional selective spinal angiography and high-speed C-arm
rotation. Additionally, high-performance image revision
software can make artifacts produced by minute body
movements disappear in the process of 3D reconstruction
and can thus provide clear 3D DS angiography images.
If angiography timing is adequately set, 3D DS angiography can clarify only the shunt point in the case of an arteriovenous fistula. Furthermore, because the workstation
provides a direct link with the angiography system apparatus, the 3D DS angiography image can be used as a reference immediately, depending on the therapeutic method
and strategy used.
Use of 3D DS angiography does have limitations. For
example, in selective 3D DS angiography, image defects
may occur in cases of a high-flow spinal arteriovenous malformation, because the rotation speed of the C-arm cannot
catch up to the shunt flow. Less visibility of tiny vessels,
lack of visibility of part of the venous structure, and temporal resolution of blood flow are also drawbacks to using
3D DS angiography, but technical improvements are expected in the near future.
Conclusions
We report on 2 patients with spinal DAVFs whose vascular structures were clearly visualized using selective spinal 3D DS angiography. This 3D DS angiography approach
J. Neurosurg.: Spine / Volume 8 / May 2008

Digital subtraction angiography for spinal DAVF
proved very useful for understanding the complex spinal
vascular architecture, selecting the best working angle, anddeveloping an appropriate therapeutic strategy during endovascular treatment for these spinal DAVFs. The usefulness of this procedure assures good operative and clinicaloutcomes for patients with these lesions.
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Manuscript submitted November 26, 2007.
Accepted January 10, 2008.
Address correspondence to: Noriaki Matsubara, M.D., 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan. email:mnoriaki0817@yahoo.co.jp.

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