Spinal arteriovenous malformation

Case contributed by Dr Henry Knipe

Presentation

Six months of lower back pain. No history of trauma or other inciting event.

Patient Data

Age: 40 years
Gender: Female
Modality: MRI

No significant degenerative change, disc protrusion or central/foraminal narrowing. Prominent T2 flow voids around the distal spinal cord. 

Modality: MRI

Intramedullary lesion with prominent T2 flow voids posterior to the T6 vertebral body with linear T2 flow voids throughout the imaged spinal cord. These are predominantly anterior, and indent the cord. There is patchy contrast enhancement and significant blooming. No significant high T2 cord signal.

Modality: DSA (angiography)

Left T8 supply to high flow spinal cord AVM, large nidus, superiorly draining veins reach to craniospinal junction (not shown), and inferiorly to the thoracolumbar region. Lateral view shows the arterial supply to enter the nidus anteriorly, AP shows it reaches the midline.

The patient presented with severe back pain a few years after the initial investigations (no treatment), and an urgent MRI was performed. 

Modality: MRI

Posterior to the T6 vertebral body is lobulated low T1 and T2 weighted lesion that expands the thoracic cord with surrounding prominent T2 flow voids within the visualised spinal canal that indent the spinal cord anteriorly. Surrounding serpiginous patchy contrast enhancement.

Blooming on T2* weighted images at T6 which was not visible on the previous MRI. High T2 cord signal from T4-T7 appears more pronounced, particularly superiorly. No syrinx. No extradural collection.

Case Discussion

The initial lumbar spine has a suspicious appearance for a spinal vascular malformation with prominent T2 flow voids, which were proven to be a spinal arteriovenous malformation. These can often be overlooked as a cause for back pain in the setting of degenerative change. This can lead to patients having spinal surgery for degenerative change, which in the end does not help their symptoms. 

On the follow-up MRI, there is new T2 cord signal and new blooming artifact, which are both suspicious for a (small) haemorrhage. This would be consistent with the patient's presentation of acute back pain. 

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Case Information

rID: 42256
Case created: 13th Jan 2016
Last edited: 12th Apr 2017
Inclusion in quiz mode: Included

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