Presentation
Initially 12 months of slowly progressive bilateral leg weakness, in the last 6 weeks rather rapidly progressive tetraplegia.
Patient Data
Cervical Myelopathy with mass effect and cloudy, patchy contrast enhancement.
Tentorial arteriovenous fistula originating from the left internal carotid artery and draining only infratentorially in perimedullary veins.
Case Discussion
Extensive cervical myelopathy with tumor-like increased diameter, patchy contrast enhancement and sparing of the thoracolumbar myelon, showing only very discrete hints for a spinal dural arteriovenous fistula (dAVF) as cause for the congestive venous myelopathy.
The origin of this type V spinal dAVF (Cognard/Merland/Djindjian classification) was the left internal carotid artery via the recurrent ramus of the inferolateral trunc (ILT) and the lateral tentorial artery (Bernasconi). Drainage via dilated perimedullary veins. So this is a tentorial dAVF with purely spinal drainage.
This case illustrates that even discrete MRI signs (like cloudy contrast enhancement) in unclear spinal myelopathy should warrant searching for dAVF, and presents an anatomical variant with tentorial spinal dAVF origin.
Case imaging courtesy of Prof. Dr. R. Chapot and PD Dr. P. Mosimann (Alfried Krupp Krankenhaus Essen, Germany).