Endovascular Treatment of Adult Spinal Arteriovenous Lesions Neeraj Chaudhary, MD, MRCS, FRCR a, *, Aditya S. Pandey, MD a , Joseph J. Gemmete, MD, FSIR b INTRODUCTION Spinal arteriovenous lesions (SAVLs) are rare. 1 SAVLs represent only 3% to 4% of all spinal cord lesions, and can be associated with considerable morbidity and mortality if left untreated. 2 Elsberg 3 was the first person to surgically treat an SAVL in 1914. He successfully treated a spinal dural arterio- venous fistula (SDAVF) with medullary venous drainage. In the early 1960s in the United States, Di Chiro and colleagues 4 pioneered selective spinal arteriography, which led to real-time recognition of the spinal cord vascular anatomy and pathology. At the same time in France, Djindjian 5 was the first to describe the technique of selective spinal angiog- raphy. Since this time, there has been an evolution in imaging, endovascular, and surgical techniques. These technological advancements and a better understanding of spinal cord pathophysiology now allow us to manage SAVLs more effectively within the context of a multidisciplinary approach involving neurointerventional radiology and cere- brovascular neurosurgery. However, there is still a lack of a comprehensive understanding of spinal cord pathophysiology, consensus in the clinical classification of the various types of SAVLs, and ambiguity in anatomic spinal cord terminology. Moreover, there are conflicting reports in the litera- ture advocating either an endovascular technique or surgery as the first line of treatment. This article discusses the anatomy, epidemiology, presenta- tion, natural history, pathophysiology, and endo- vascular treatment of the various types of SAVLs in adults. a Division of Interventional Neuroradiology, Departments of Neurosurgery and Radiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5030, USA; b Division of Inter- ventional Neuroradiology and Cranial Base Surgery, Departments of Radiology, Neurosurgery, and Otolaryn- gology, University of Michigan Health System, UH B1D 328, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5030, USA * Corresponding author. E-mail address: neerajc@med.umich.edu KEYWORDS  Spinal arteriovenous lesions  Spinal angiography  Spinal cord arteriovenous malformation  Spinal arteriovenous fistula  Spinal dural arteriovenous fistula  Epidural arteriovenous fistula KEY POINTS  Spinal arteriovenous lesions (SAVLs) are rare.  Spinal dural arteriovenous fistulas (SDAVFs) are the most common SAVLs.  Diagnosis is difficult, and a high clinical index of suspicion is recommended.  Magnetic resonance imaging should be the noninvasive imaging modality of choice to confirm the diagnosis.  Selective spinal angiography remains the gold standard for the evaluation of SAVLs.  The optimal treatment modality, either endovascular or surgical, remains to be established. Neuroimag Clin N Am 23 (2013) 729–747 http://dx.doi.org/10.1016/j.nic.2013.03.017 1052-5149/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved. neuroimaging.theclinics.com