title: Spinal Dural Arteriovenous Fistula: Is There a Role for Intraoperative Contrast-Enhanced Ultrasound?
abstract: BACKGROUND
  Intraoperative imaging during surgical ligation of a spinal dural arteriovenous fistula (SDAVF) is usually based on fluorescence angiography, intraoperative Doppler ultrasound, and intraoperative digital subtraction angiography. We investigated the potential role of contrast-enhanced ultrasound (CEUS) during surgical management of SDAVF. The main features of SDAVF on CEUS before treatment are described as well as their modifications after surgical ligation.
  
  
  METHODS
  CEUS was performed using harmonic imaging with a second-generation ultrasound contrast agent in a case of right D6 SDAVF. Initial CEUS scan demonstrated the location of the arterialized vein draining in the dilated perimedullary plexus and augmented enhancement of the spinal cord secondary to intramedullary capillary congestion and augmented flow. The postligation scan demonstrated interruption of the arterialized vein and restoration of normal blood flow in spinal cord and perimedullary plexus.
  
  
  CONCLUSIONS
  CEUS allowed real-time visualization before and after ligation of the site of the fistula and blood flow changes occurring in the spinal cord and perimedullary plexus. CEUS is a valuable tool in SDAVF surgery without the limitations of Doppler imaging and possibly can be integrated with other imaging modalities such as fluorescence angiography.
authors.affiliation: Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy. Electronic address: francesco.prada@istituto-besta.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Prada
authors.affiliation: Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Del Bene
authors.affiliation: Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faragò
authors.affiliation: Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy; Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland, USA.
authors.forename: Francesco
authors.initials: F
authors.lastname: DiMeco
mesh_terms: D000368:Aged; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging* / Q000601:surgery*; D003287:Contrast Media; D006801:Humans; D008026:Ligation; D008297:Male; D019635:Neurosurgical Procedures; D013116:Spinal Cord / Q000098:blood supply / Q000000981:diagnostic imaging* / Q000601:surgery*; D018084:Ultrasonography, Interventional
chemical_list: D003287:Contrast Media
keywords: Contrast-enhanced ultrasound; Intraoperative ultrasound; Spinal dural arteriovenous fistula; Surgical ligation; Vascular malformation