results of surgical treatment patients spinal angioma

Journal of Neurology, Neurosurgery, and Psychiatry, 1974, 37, 1074-1081

Results of surgical treatment for patients with aspinal angioma

VALENTINE LOGUE, M. J. AMINOFF, AND B. E. KENDALL

From the National Hospitals for Nervous Diseases, Maida Vale Hospital,and the Institute of Neurology, Queen Square, London

SYNOPSIS The clinical, angiographic, and operative findings in 16 patients with a spinal angiomaare reviewed, and the results of surgery are assessed. The surgical procedure employed in 15 patientsconsisted of excision of the fistulous portion of the malformation, achieved by intradural ligation ofits feeding vessels and excision of its draining veins throughout the limits of the exposure. In 14patients, a previously progressive deterioration in their clinical condition was arrested by surgicalcorrection of the malformation and in 12 of these patients there was worthwhile improvement infunctional capacity. The optimal time for surgical treatment is considered and suggestions aremade for the manner in which patients should be investigated.

There has been a recent resurgence of interest inpatients with spinal angiomas, due to refine-ments in neuroradiological techniques whichhave led to a more active approach to theirsurgical management. We have recently reviewedthe clinical features of a large group of patientswith this disorder and defined the natural historyand prognosis in 60 untreated cases (AminoffandLogue, 1974a, b). It seemed an appropriate time,therefore, to assess the results of correctivesurgery in such patients.

Spinal angiomas are vascular malformations,presumably congenital in nature, which consistof an anomalous intradural, but usually extra-medullary, arteriovenous fistula. They are morecommon in males than females. The onset ofsymptoms is usually delayed until middle-agewhen a progressive paraparesis and parapara-esthesis develop, with early derangement ofbowel and bladder function (Aminoffand Logue,1974a). There is no satisfactory medical treat-ment of the anomaly. There have been a numberof recent publications concerning the results ofsurgical treatment, but in most of these onlylimited clinical details are provided; accordingly,it is often difficult to assess satisfactorily eitherthe benefits of surgery with respect to the func-tional capacity of patients, or the surgical mor-bidity. For this reason, we have analysed in

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detail the response of a series of patients to sur-gical treatment, and have defined the manner inwhich we believe future patients should beinvestigated and managed.

METHODS

Fourteen of the patients in our earlier series (Aminoffand Logue, 1974a) were operated upon by one of us(V.L.) and form the subject matter of this report. Twoother patients who presented here more recently andwho came to operation have also been included.The response to operation has been assessed by

reference both to the symptoms and signs, and to thefunctional capacity of patients. The symptoms andsigns are considered in terms of overall motor,sensory, and sphincter disturbance, rather than in amore detailed manner which would have necessitatedthe use of a cumbersome scoring system. Even insuch broad terms, however, their relationship tofunctional disability may be indirect and tenuous.Since the more important parameter to the patientis clearly that of functional capacity, we have pre-ferred to study this in greater detail.We have rated functional capacity in the manner

of our earlier study (Aminoff and Logue, 1974b) but,for convenience, the appropriate definitive criteriaare recapitulated in Table 4.

Seven of these patients had continued to attendhere regularly for follow-up. One of the remainingpatients had attended for follow-up at anotherhospital until his death, and his notes were kindly

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Results of surgical treatment for patients with a spinal angioma

TABLE 1CLINICAL FEATURES

Case no. Age (yr) Symptomns Leg Signs, sensation impaired Comnmentssex (in order of weakness

onset) Superficial JPS Vib

I T.A. 64 M S M I Sp R>L L4-S5 + +(A50782)

2 C.B. 47 M M Sp S R=L L2-S5 + + Symptoms aggravated by exercise(A48639)

3 J.B. 63 M M SSp I R<L T1O-S5 + + Symptoms aggravated by exercise and(67589) certain postures

4 W.B. 63 M Sp S M I R=L Ti -S5 + + Symptoms aggravated by exercise(A26156)

5 C.C. 60 M S M Sp R < L T12-S5 - + Symptoms aggravated by certain(A56203) postures

6 S.C. 64 M S I Sp M R=L T6-S5 + + Symptoms aggravated by exercise(A42041)

7 A.D. 58 M S M Sp I R=L L55 - +(A53748)

8 U.P. 33 F S M Sp R=L Sl-S5 - - Symptoms related to pregnancy and(A59239) certain postures

9 J.DeQ. 55 M S M Sp I R>L T8-S5 + +(A55886)

10 N.S. 55 M M Sp S R=L L2-S5 + + History of preceding trauma. Symptoms(A63384) aggravated by exercise

11 E.S. 53 M S Sp M R < L SI-S5 - + Symptoms aggravated by certain(A35108) postures

12 D.T. 44 M S I M Sp L S1-S5 + + Partial Brown-S6quard syndrome(A28642)

13 W.W. 50 M S M Sp R=L T1O-S5 + + History of preceding trauma; symptoms(A67666) aggravated by exercise, certain

postures and administration ofACTH

14 H.T. 58 M Myoclonic L T2-S5 + + 6 subarachnoid haemorrhages in pre-(65485) jerking (and L arm) ceding 17 years

M Sp15 E.H. 73 F M Sp S R<L T9-S5 + +

(A70782)16 T.W. 51 M S M Sp I R>L T12-S5 + + Symptoms aggravated by exercise

(76499)

M: motor disturbance; S: sensory disturbance; Sp: sphincteric disturbance; I: impotence; JPS: joint position sense; Vib; vibration sense.

made available to us. The other eight patients wereseen here by one of us (M.J.A.) for the purpose ofthis study.

RESULTS

The clinical data relating to the preoperativestate of our patients (Table 1) indicate that themajority of patients were middle-aged males(Aminoff and Logue, 1974a). In several casessymptoms were related to preceding trauma, oraggravated by exercise or certain postures. Mostpatients had a combination of motor, sensory,and sphincter disturbances (Tables 1 and 4). Inall 16 patients clinical examination suggestedthat there was a severe disturbance of functionin the spinal cord.

MYELOGRAPHY In all cases, myelographyshowed characteristic, tortuous filling defects

due to elongated, distended veins. In fourpatients these vascular impressions convergedupon an area which was subsequently -shownangiographically to be the site of the anomalousshunt, and in some instances a small projectionfrom the cord shadow was visible in this position(Figure, a). In two patients (cases 5 and 8) afeeding artery to the angioma was tentativelyrecognized at myelography confirmation beingobtained angiographically-as a linear shadowrunning toward the cord from the side of thetheca near the exit of a nerve root. Myelographywas followed by temporary exacerbation of legweakness in case 4, but no other sequelaeoccurred when performed here.

AORTOGRAPHY Aortography was performed inthree of the earlier patients in an attempt to

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1076 Valentine Logue, M. J. Aminoff, and B. E. Kendall

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FIGURE Case 8. (a) Myelogram, prone film. The feeding artery (black arrows) and descending vein (hollowarrows) are outlined. These vessels converge towards a constant defect (asterisks) caused by the nidus of vesselsin the region of the shunt. The theca above the shunt is incompletely filled but draining veins are partly outlinedin this region also. (b) Spinal angiogram, selective injection of right 2nd lumbar artery. The feeding artery(black arrow) ascends along the right side of the theca to D12-LI vertebral level before crossing the mid-line tosupply the shunt (asterisks). Draining veins mainly ascend, but a fairly large descending vein is indicated(hollow arrow).


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Results of surgical treatmenit for patients with a spinal angioma

TABLE 2ANGIOGRAPHIC FEATURES

Case Upper level of Shunt at angiography Feeding arteries Direction of Local radicularn1o. clinical signs renous drainage branch to

(corresponding Vertebral Site anterior spinalvertebral level) level artery

1 L4 (DlI) DlI R posterolateral R subcostal Rostral L 2nd lumbar2 L2 (D10) D7-8 R posterolateral R 8th intercostal Rostral R 10th intercostal3 D10 (D7-8) D6 R posterolateral R 6th intercostal Rostral and caudal L 9th intercostal5 D12 (D9) DI0 Posterior L subcostal Rostral and caudal L 10th intercostal6 D6 (D4) D6-7 Posterior R 7th intercostal Rostral L 9th intercostal

(R 8th intercostal)7 L5 (D12) D9-10 Posterior R 9th intercostal Caudal L 11th intercostal8 Sl (Ll) D12-LI L posterior extending R 2nd lumbar Rostral L subcostal

anteriorly L 10th intercostal9 D8 (D5-6) D4 Posterior R 4th intercostal Rostral and caudal R 8th intercostal10 L2 (DIO) D7 Posterior R 8th intercostal Caudal Failed to fill

(R 7th intercostal)13 D10 (D7-8) D10 L posterolateral L 11th intercostal Rostral L 10th intercostal14 C6-7 (C6) C5-6 Mainly posterior L & R deep cervical Rostral L vertebral

via L C6-7, R C5-6& R T1-2 i.v. spaces

15 D9 (D6-7) D9 R posterolateral R 8tlh intercostal Mainly rostral, L 7th intercostal(R 9th intercostal) some caudal

16 D12 (D9) D9 R posterolateral R 9th intercostal Rostral L 10th intercostal(R 8th intercostal)

Cases 4, 11, and 12 were investigated by aortography and have therefore been omitted from this Table.Feeding vessels providing a secondary supply to the angioma are placed in parentheses.

visualize the malformation. No abnormalitywas seen in case 11, while in case 12 there wassome filling of the malformation but the vascularsupply to it could not be identified with certainty.In case 4, tortuous vessels were identified to theleft of the theca at the 11th thoracic vertebrallevel, but again it was not possible to identifyclearly the segmental feeding arteries. Onepatient (case 12) developed flexor and adductorspasms of the leg with each injection of contrastmaterial, but there was no change in his motoror sensory signs.

SELECTIVE SPINAL ANGIOGRAPHY In 12 patients,selective spinal angiography with opacificationof all segmental arteries permitted the angiomaand its feeding vessels to be visualized (Table 2;Figure, b). The angioma was situated at or be-low the level of the 6th thoracic vertebra, corre-sponding approximately to a level at or below the8th thoracic segment of the spinal cord, in mostcases. In several instances, however, the level atwhich clinical signs were present differed by upto two or three segments from the level of themalformation. The angioma was supplied byonly a single segmental feeding vessel in seven ofthe 12 cases. In five patients, two feeding arterieswere identified, and in all but one case theyoriginated in adjacent intercostal vessels. The

local radicular branch to the anterior spinalartery was not involved in feeding the malforma-tion in any of our patients. The angiographicprocedure was followed by a transient clinicaldeterioration in three patients; there was an in-crease in the sphincter disturbance of case 5, inthe leg weakness of case 9, and in the weakness,sensory, and sphincter disturbances of case 3.

In case 14, bilateral vertebral and subclavianangiography was performed in view of theclinical and myelographic localization of themalformation to the cervical region. This pro-vided information essential to the planning ofcorrective surgery (Table 2).

SURGERY In the 12 patients in whom the mal-formation was defined by selective spinal angio-graphy, its localization was confirmed at opera-tion. In cases 8, 10, and 15, only one segmentalfeeding vessel was identified at operation,although two were demonstrated angiographic-ally (Table 3). However, no extradural searchwas made and it may be that the two feedingvessels united in this region to form a singlevessel penetrating the dura mater to supply themalformation, as was demonstrated in case 16.Temporary clamping of the feeding vessel re-sulted in a reduction in bulk or pulsation of themalformation and/or darkening in colour of the

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TABLE 3OPERATIVE FINDINGS

Case No. of segmentalfeeders Source of Intra-no. feeding vessels medullary

at selective at componentangiography operation

1 1 1 Posterior 02 1 1 Posterior 03 1 1 Posterior 04 NP 2 Anterior and posterior 05 1 1 Posterior (accessory 0

brs. from anterior)6 2 2 Posterior 07 1 1 Posterior 08 2 1 Anterior +9 1 1 Posterior 010 2 1 Posterior 011 NP None identified +12 NP I Posterior +13 1 1 Posterior 015 2 1 Posterior 016 2 2 Posterior 0

NP: not performed.In cases 4, 11, and 12, aortography was undertaken, but the segmentalarteries feeding the malformation were not visualized.Laminectomy was not performed in case 14 who has therefore been

omitted from this table.The source of the feeding vessel was determined in each case by the

location of the nerve root it accompanied.

blood contained within it, in 11 of the 12 patientsin whom this manoeuvre was performed, butsuch changes were sometimes slow to develop,as noted previously by Ommaya et al. (1969). Inthree patients the presence of an intramedullarycomponent of the malformation was implied bylocal swelling of the cord, with vessels emergingfrom it to connect with the extramedullary ves-sels comprising the malformation (Table 3).The surgical procedure adopted was intradural

ligation of the vessel or vessels feeding theangioma, combining their removal with excisionof the fistulous communication and its enlargeddraining veins throughout the length of the ex-

posure which usuallyextended over three laminae.The dissecting microscope has facilitated the tech-nical aspects of excising the malformation.

This procedure was used in all patients exceptcase 14 in whom the malformation was fed by thedeep cervical arteries; they were easily accessibleto extravertebral ligation and the malformationitself was not excised in view of the rapid im-

TABLE 4RESPONSE TO SURGICAL TREATMENT

Case E-xcision Follow-up Individual symptoms, Functional incapacityno. (yr) signs --(yr) signs

Gait Disturbed DisturbedM S Sp micturition defaecation

Preop. Postop.Preop. Postop. Preop. Postop.

I Complete 4% + + 0 2 1 1 1 1 12 Complete 44 + + + 5 4 3 2-3 2 13 Complete 2 + + 0 5 4 3 3 2 24 Complete 54 + + 0 5 4 3 3 2 25 Incomplete* 24 + 0 + 3 2 1 N 1 16 Complete 2 + + 0 4 4 2 2 2 27 Complete 3% + + 0 3 2 3 3 2 28 Incompletet 3 + 0 + 3 1 3 N 3 19 Complete 2 + + - 2 1 1-2 2 1 210 Complete !4 - + 0 3 4 1 1 1 N11 Incompletet 7 + + + 2 1 1 N 1 N12 Incompletet 3 - - - 1 4 1 2 2 113 Complete 4 + + + 4-5 2 2 1 1 114 Not performed (feeding

vessels ligated extra-vertebrally)t 5 + + + 1 N 1 N N N

15 Complete i + 0 + 5 4-5 3 2 N N16 Complete 4 + + + 4 3 3 1 3 1

Symptoms and signs+: improved; 0: no change; -: worse; M: motor deficit; S: sensory deficit; Sp: sphincter disturbance.Functional disturbancesN: normal.Gait: 1-onset of leg weakness, abnormal stance or gait, without restriction of activity; 2-restricted activity; 3-requires one stick or somesupport for walking; 4-requires crutches or two sticks for walking; 5-unable to stand, confined to bed or wheelchair.Micturition: 1-mild-hesitance, urgency or frequency; 2-moderate-occasional urinary incontinence or retention; 3-severe-total urinaryincontinence or persistent retention.Defaecation: 1-mild-constipation; 2-moderate-occasional faecal incontinence or severe intractable constipation; 3-severe-totalfaecal incontinence.The postoperative incapacity indicated relates to the condition of patients at the time of their last follow-up assessment.* Case 5-anterior extension of angioma left in situ.t Cases 8, 11, 12-intramedullary component of angioma left in situ.t Case 14-myoclonic jerking now settled completely.

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provement that followed these initial surgicalprocedures. In one patient (case 15) an attemptwas made to occlude the feeding vessels to theangioma by embolization with gelfoam. One ofthe two feeding vessels was completely occludedthereby but the other remained patent. More-over, when the angiographic studies were re-peated 24 days later, it was clear that both vesselswere again feeding the malformation, andaccordingly the patient was operated upon in ourusual manner.

RESULTS OF SURGERY The response to surgicaltreatment is indicated in Table 4. The majorityof patients were moderately or severely disabledbefore surgery. Nevertheless, in all but two ofthe 16 cases, treatment led to arrest of a pre-viously progressive course.No severely incapacitated patient regained a

normal gait. The functional disturbance in thelegs improved by one grade in ten patients, andby two grades in two patients (cases 8 and 13)who were operated upon relatively soon aftertheir gait disturbance had become severe, andpresumably, therefore, before damage to thespinal cord had become irreversible.

Control of micturition improved in sevenpatients, in four of whom it returned to normal.Disturbances of defaecation similarly becamemilder in six patients. In two patients (cases 8and 16) there was a marked improvement in thesevere disturbance of both micturition anddefaecation which each had developed beforesurgery. There was otherwise little correlationbetween changes in the control of micturitionand defaecation as a result of surgery.

It is of some importance to consider the pos-sible causes for the continued decline that occur-red in two patients. In case 12, the malformationwas excised but an intramedullary componentwas left undisturbed. This patient initiallyshowed improvement in motor and sphincterdisturbances, but about two months after surgerythere was an abrupt increase in all his symptomswhich then gradually worsened over the follow-ing three years until his death. In view of its timecourse, it seems reasonable to attribute thisdeterioration to the intramedullary componentof the angioma, rather than to the effects ofsurgery. In case 10, reduction in functional

capacity followed immediately after operationand he now requires two sticks instead of one forwalking. This deterioration, which has not pro-gressed, presumably relates to the operationitself.

Postoperative angiography was performed inonly one of our cases, but showed the mal-formation to have been obliterated completely.

DISCUSSION

Until comparatively recently, attempts to treatpatients with a spinal angioma by surgery wereusually futile and, in some cases, led to increasedfunctional disability. In particular, the results ofdecompressive surgery were disappointing. Ithad accordingly been our policy to delay opera-tion until patients were severely incapacitatedand, as a consequence, the majority of patientsreported here were moderately or severely dis-abled, and were continuing to deteriorate, at thetime of treatment. A more active approach to themanagement of such patients has been fosteredby recent developments in neuroradiology whichhave permitted the accurate preoperative de-lineation of these malformations and their feed-ing vessels. The results of such active surgicaltreatment in our patients indicate that worth-while improvement in the functional capacity andsymptoms can be expected after excision of theangioma. Furthermore, we anticipate that evengreater improvement will follow operation at anearlier stage in the natural history of the dis-order, when the degree of irreversible damage tothe spinal cord will be less marked.

It is important to consider our findings inrelation to those of others. Shephard (1963,1965) treated 11 patients by excision of the mal-formation without preoperative angiographicdelineation. While the result of treatment isindicated, the criteria used in its evaluation arenot provided and insufficient data are presentedto permit independent assessment. Patientsjudged to have shown a 'good' result in thatauthor's series were those in whom the disabilitywas present for only a few weeks and in whomsome degree of spontaneous improvement mighthave been anticipated (Aminoff and Logue,1974b). Krayenbiihl et al. (1969) reported aseries of 17 patients treated by surgical excisionof the malformation. As in our series, the

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majority of patients were male, and the mal-formation was located in the thoracic or lumbo-sacral regions, save in one case. These authorsprovide no details ofthe durations offollow-up intheir cases, and-perhaps because angiographywas not used routinely to localize the site of thefistulous shunt-attempted a total excision ofthe enlarged draining veins after laminectomywhich often extended over six or more vertebrae.Moreover, the results of surgery were judged tobe 'excellent' in patients who had little or no pre-operative deficit and in whom the malformationwas removed without incurring any significantincrease in deficit. This clearly implies an evalua-tion of surgical morbidity rather than the effectof excision on the natural history of the con-dition. For these reasons, we consider that thisstudy is not entirely satisfactory in permitting anindependent assessment of the results of surgery.Kunc and Bret (1969) reported a series of nine

patients treated either by excision of the mal-formation or by ligation of feeding vessels, butinsufficient data are provided of the pre- andpost-operative functional capacities of individualpatients to permit adequate assessment of theirsurgical results. Various surgical procedureswere also employed by Djindjian et al. (1969) inthe treatment of 29 patients, complete excisionbeing undertaken in 19 instances. Twelve ofthese patients showed some improvement but itis difficult to assess the significance of this, in theabsence of further clinical details; the otherseven, who were completely paraplegic beforesurgery, showed no meaningful response totreatment.Ommaya et al. (1969) have treated 11 patients

by intradural ligation of all feeding vessels, with-out excision of the fistula: there was symptom-atic improvement in all cases but one, in whom,however, insufficient time had elapsed for ade-quate assessment. In at least five of these patientsthere was significant improvement in gaitdisturbance.We are unaware of a follow-up study on the

more long-term prognosis of surgically treatedpatients with spinal angioma. It is, therefore,difficult to ascertain whether intradural ligationof feeding vessels is, in itself, as satisfactory aform of treatment as when combined withexcision of the malformation. Moreover, thepoint would not be satisfactorily resolved by a

comparison of the results gained in differentcentres since individual differences in surgicalskill and postoperative paramedical care mightlead to bias. In view of the possibility that feed-ing vessels, unrecognized at angiography oroperation, may be left undisturbed and continueto supply the malformation-as in one of the'incompletely treated' patients of Ommaya etal. (1969)-we believe that concomitant excisionof the fistulous anomaly is the more satisfactoryprocedure.

INDICATIONS FOR SURGERY We have recentlyconsidered in detail the natural history of 60 un-treated patients with spinal angioma (Aminoffand Logue, 1974b). Patients may remain asymp-tomatic for years, but once symptoms developthey may progress with great rapidity. Thus,within six months of the development of anyfunctional impairment in the legs, 19% ofpatients were either confined to bed or requiredtwo sticks/crutches for walking, and a similardegree of disability had developed in 5000 ofpatients by three years. However, in otherpatients the disability remained mild for manyyears after the development of symptoms. Inview of these observations, we suggested that therapidity ofprogression in neurological deficit andincapacity provides a useful guide to the mostappropriate time for surgical correction of thevascular anomaly; in cases with a slow rate ofprogression, however, treatment may becomemandatory when the cumulative disabilitybecomes restrictive.

MYELOGRAPHY The diagnosis of spinal angiomais suggested by myelography which is best under-taken with a large volume of positive contrastmaterial and performed with the patient bothprone and supine. Tortuous filling defects, duemainly to elongated distended veins and occur-ring without evidence of tumour or obstruction,are characteristic, but larger filling defects due toaneurysmal distension of veins, or partialobstruction due to arachnoiditis, may occuroccasionally. As indicated above, the site of thefistula may sometimes be indicated by myelo-graphy from the manner in which vascularimpressions converge upon it, and in such in-stances there may be a smooth projection fromthe cord shadow, caused by the vessels forming

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the shunt itself. It may also be possible to recog-nize tentatively a feeding artery extendingtoward the cord from the side of the theca near anerve root. These additional features are helpfulin planning selective angiography which, how-ever, is best delayed until surgical treatment iscontemplated.

SELECTIVE ANGIOGRAPHY It has been our usualpractice at angiography to opacify all the seg-mental feeding vessels to the spinal cord. How-ever, the reappraisal occasioned by this studysuggests that a more limited approach would beadequate. The clinical and myelographic data inindividual cases should determine which vesselsare injected first. If a vessel is located whichfeeds the malformation without implicating theanterior spinal artery, we suggest that the threesegmental arteries above and below it, and thecorresponding contralateral vessels, are injected;in the majority of cases, this will localize anysimilar vessel feeding the malformation. In thecervical region, because the segmental vesselsare modified during foetal development, thethyro- and costa-cervical trunks, and thevertebral arteries should be injected. In theplanning of corrective surgery, it is importantalso to localize the anterior radiculo-medullaryartery supplying the anterior spinal artery in theregion of the shunt, as it may also be implicatedin the fistulous malformation-a relatively un-common occurrence in our experience-and todefine its relationship to the proposedoperativefield. If the anterior spinal artery supplies anangioma which is located several segments awayfrom the main segmental contribution to thisvessel, the segmental arteries in the vicinity of thefistula must also be visualized. Accordingly, wesuggest that the angiographic procedure is con-tinued until this has been achieved and then isterminated.We propose to perform such angiographic

studies, which, though limited in scope, never-theless provide all the information required inplanning elective surgery, in the management of

future patients. The only exception to this rule isan angioma in the lumbar region, in the investi-gation of which all lumbar and lateral sacralvessels below the shunt should be visualized, asascending feeding vessels are not uncommon insuch cases. The operation site itself will bedetermined by the angiographic findings, since,as indicated above, there may be a discrepancy ofseveral segments between the clinical and radio-logical location of the malformation. Post-operative angiography, limited to showing thatthe aims of surgical treatment have been achieved,was performed in only one ofour patients, but wesuggest that this should be performed routinely,since the information it provides may be of prog-nostic significance.

CONCLUSION

In our series of 16 patients deterioration attribut-able to surgery occurred in one patient, a pre-viously progressive course was arrested in 14patients, and worthwhile improvement in func-tional capacity occurred in 12 of them.

REFERENCES

Aminoff, M. J., and Logue, V. (1974a). Clinical features ofspinal vascular malformations. Brain, 97, 197-210.

Aminoff, M. J., and Logue, V. (1974b). The prognosis ofpatients with spinal vascular malformations. Brain, 97,21 1-218.

Djindjian, R., Houdart, R., and Hurth, M. (1969). LesAngiomes de la Moelle. Sandoz: Paris.

Krayenbuihl, H., YaSargil, M. G., and McClintock, H. G.(1969). Treatment of spinal cord vascular malformationsby surgical excision. Journal of Neurosurgery, 30, 427-435.

Kunc, Z., and Bret, J. (1969). Diagnosis and treatment ofvascular malformations of the spinal cord. Journal ofNeurosurgery, 30, 436-445.

Ommaya, A. K., Di Chiro, G., and Doppman, J. (1969).Ligation of arterial supply in the treatment of spinal cordarteriovenous malformations. Journal of Neurosurgery, 30,679-692.

Shephard, R. H. (1963). Observations on intradural spinalangioma: treatment by excision. Neurochirurgia (Stuttgart),6, 58-74.

Shephard, R. H. (1965). Some new concepts in intraduralspinal angioma. Rivista di Patologia Nervosa e Mentale, 86,276-283.

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