The patient is a male in his 60s with a past medical history significant for pulmonary sarcoidosis. He was referred to neurology clinic for progressive, bilateral, lower extremity numbness which he noted first in his feet. The patient indicated the pain and tingling in his feet worsened with prolonged standing and walking. He also endorsed lower back pain on follow-up visits. MRI of the thoracic cord demonstrated a longitudinally extensive transverse myelitis. The initial workup was unrevealing for an etiology and initial suspicions were that his condition was due to neurosarcoidosis. A lumbar puncture was performed and negative. Upon further review of the spinal imaging it was thought that there may be dilatation of the spinal epidural venous plexus, which would potentially indicate a dural arteriovenous fistula. The patient was then taken for a catheter angiogram for further evaluation.\nDuring angiography, the left and right subclavian arteries were imaged to evaluate for spinal cord blood flow. An injection within the aorta was required to establish a road map for the left vertebral artery and the left vertebral artery origin from the aortic arch was found. An injection of the aortic arch origin of the vertebral artery revealed complete filling of all segments of the left vertebral artery. Retrograde filling of the left subclavian artery was seen indicating a potential dual origin from the left subclavian artery. A catheter was placed within the left subclavian and a second origin of the left vertebral artery was appreciated to originate and merge with the aortic V1 segment at the level of the C5 vertebrae (Figure ). Equal filling was seen from both the aortic and subclavian origin. No aneurysms or dissections were appreciated in either origin or at the confluence. When the right T7 spinal artery was injected, a dAVF was observed. The fistula originated from a distal branch of the spinal artery and combined with an anterior spinal vein with abnormal filling appreciated. The rest of the spinal arteries were interrogated and noted to be grossly normal without aneurysms, fistulas, or other vascular abnormalities.\nPost-procedure and follow-up\nThe patient underwent embolization of the right T7 spinal artery was performed with obliteration of the fistula (Figure ). The patient tolerated the procedure well without complication and was discharged home.
A 43-year-old Caucasian man was admitted to the emergency department of our hospital for headache associated with weakness of the left limbs. He had no medical history, he denied even slight trauma of the neck, and his only cardiovascular risk factor was tobacco smoking for 10 years. Neurological examination revealed verbal aphasia and left hemiparesis.\nDuring CT angiography (TK–64-row MDCT scanner, LightSpeed VCT, GE, Waukesha, WI) of the neck and head, segmental dissections of the right internal carotid artery (ICA) at the level of the cranial basis were discovered (Fig. a). The lumen of the ICA was decreased to 4 × 2.5 mm (60 % of normal flow). Cerebral CT showed a recent infarction involving the medial part of the right temporal lobe and deep structures of the right hemisphere including the thalamus, the genu and the posterior limb of the internal capsule (Fig. b).\nCT angiography of the neck and head also showed a duplication of the left vertebral artery (LVA) with two origins, both from the left subclavian artery (Figs. , ). The duplicated segments were fused at level of the C5–6 vertebrae into a single vertebral artery, which then entered the transverse foramen of C5 (Fig. ). All measurements were taken on an Advantage Workstation (GE).\nThe first LVA originated from the left subclavian artery at a distance of 7 mm from the aortic arch. It measured 2.9 and 2.8 mm in diameter at the points of origin and just before fusion, respectively (Fig. ). The course of the artery was 101 mm. The second LVA arose from the left subclavian artery 37 mm distal to the first (44 mm from the aortic arch). It measured 2.4 and 2.2 mm in diameter at the points of origin and just before fusion, respectively (Fig. ), and its course was 89 mm. Both vertebral arteries possessed a regular lumen. The diameter of the LVA after fusion was 3.3 mm (at level C5–6) (Fig. ).\nThe right VA arose as the first branch from the left subclavian artery, 43 mm from the aortic arch. Its course was normal. The diameters of the right VA were 4 mm at the points of origin and 3.8 mm at the C5–C6 vertebrae (Fig. ). Both thyrocervical trunks were seen to originate separately from the subclavian arteries.\nAdditionally, complementary but independent to CT angiography Doppler Sonography B-flow mode (Vivid 7 Pro, GE) of the vertebral arteries also revealed a duplicated LVA (Fig. ).\nAfter all procedures were completed, Ehlers–Danlos syndrome type IV was diagnosed.