Spinal dural arteriovenous fistula

Case contributed by Frank Gaillard

Presentation

Progressive paraparesis, and sphincter problems.

Patient Data

Age: 50 years
Gender: Male

Lumbar spine MRI

mri

The conus and lower thoracic cord demonstrate increased T2 signal centrally without a convincing mass or focal region of abnormal enhancement, although the entire region demonstrates faint enhancement. Along the dorsal aspect of the cord, numerous tortuous flow voids are demonstrated.

Conclusion:

Features are those of a spinal dural arteriovenous fistula with venous hypertension.

Thoracic spine MRI

mri

Profound increased T2 signal in the lower spinal cord is associated with prominent flow voids, particularly over the dorsal aspect of the cord.

There are two areas of arteriovenous shunting filling from nerve root sheath to perimedullary veins.  

A common trunk supplies the third and fourth intercostal arteries. The highest fistula is from the right third intercostal. The drainage from this level was into tortuous perimedullary veins around the cervical and upper thoracic cord.

A second separate lower fistula filled from a right sixth intercostal branch, with drainage being preferentially inferiorly into distended perimedullary veins; these account for the flow voids seen on the initial MRI.

Case Discussion

Typical appearances of a spinal dural arteriovenous fistula, demonstrating the need to complete a full spinal angiogram as not only can the source be distant form the clinical and MRI abnormality but multiple fistulae may be present. 

Case courtesy of A/Prof Peter Mitchell, Royal Melbourne Hospital. 

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