• Ran Harel, Gil Kimchi, Gal Yaniv, David Orion, and Nachshon Knoller.
• Spinal Surgery Service, Department of Neurosurgery, Sheba Medical Center Affiliated to Sackler Medical School, Tel-Aviv University, Ramat-Gan, Israel; Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center Affiliated to Sackler Medical School, Tel-Aviv University, Ramat-Gan, Israel. Electronic address: Ran.Harel@sheba.health.gov.il.
• World Neurosurg. 2021 Mar 1; 147: e354-e362.

BackgroundSpinal dural arteriovenous fistulas (SDAVFs) are rare vascular malformations. Digital subtraction angiography is the modality of choice to demonstrate the malformation before endovascular embolization or open surgical repair. Angiographically occult SDAVFs have been previously reported. Surgical considerations in SDAVFs with misleading angiography findings have not yet been assessed.MethodsA retrospective evaluation of charts and imaging files of patients operated on for SDAVF in 2018-2019 at a single institution was performed. All patients were referred to surgery following failure of endovascular embolization or owing to clinical and radiographic deterioration in the presence of an angiographically occult lesion. Cases were comprehensively reviewed and evaluated for surgical considerations in these lesions.ResultsThis case series included 4 cases. Two patients underwent embolization before surgical repair but continued to deteriorate neurologically, and 2 patients had a failed embolization attempt owing to a torturous vascular network. In all 4 patients, exploration was successful, yielding either improvement or stabilization of neurological status. Indocyanine green injection for microscopically integrated fluorescent angiography contributed to the identification of the supplying vessels and confirmed the SDAVF closure.ConclusionsSDAVFs should be treated promptly after diagnosis. In cases with high suspicion for SDAVF with occult or misleading angiography findings, spinal exploration should be pursued with no delay. Indocyanine green-assisted microscopic angiography may contribute to exploratory spine surgery for SDAVF closure.Copyright © 2020 Elsevier Inc. All rights reserved.

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