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 69-year-old female patient presented with headache for 30 days. She had no other clinical manifestation or significant past medical history. There was no abnormal finding at the initial neurological examination.\nShe underwent cranial magnetic resonance image (MRI) with 3D time-of-flight (TOF) intracranial MRA and gadolinium-enhanced neck MRA, using 1.5T system (Signa Excite, GE Medical Systems, Milwaukee, WI, USA). Routine cranial MR images revealed no significant focal lesion in the brain parenchyma. 3D TOF intracranial MRA was also normal. Contrast-enhanced neck MRA demonstrated a duplication of the right VA with two origins from ipsilateral SCA before the origin of right internal thoracic artery (Fig. ). The two limbs of duplicated VA confined to proximal V1 segment, and converged to form one main trunk at the 3.6 cm distal from each orifice. The first and second limbs of duplicated V1 segment measured 2.8 and 2.6 mm in diameter at the points of origin, respectively. The distance between two limbs calculated 8.0 mm. The diameter of the common trunk of right VA was 3.8 mm at the point of reconstitution. On the left side, the VA arose from the left SCA and measured 4.1 mm in diameter. There was no other vascular abnormality in the major cervical arteries. The patient was managed conservatively and the patient’s clinical symptoms were relieved after 7 days.