A 51-year-old male, with a medical history of hypertension and diabetes mellitus, was admitted to the local hospital due to intermittent acute exacerbation of myelopathy for 3 months. One year earlier, he had developed gait disturbance and difficulty in balancing. There was no history of trauma. Nine months later, the patient had acute onset of paraparesis after waking up in the morning. He collapsed on the ground and could not stand up for a while. After 30 min, he could raise his legs and walk as baseline. He complained of minimal back pain and denied numbness. Two months before hospitalization, he could not stand up after having dinner in the evening. After 30 min later, his symptoms improved. He had occasionally numbness on his left leg. After this event, he had a limitation on ambulation and was unable to walk more than about 50–100 m without stopping to rest. No bowel or bladder involvement was complained. Three weeks before admission, the patient had the same symptoms and rest for about 30 min then improved. MRI of whole spine was performed and was interpreted of a long segment T2 hyperintense cord lesion extending from the level of T4 to the conus medullaris. Lumbar puncture was performed due to the putative diagnosis of transverse myelitis. Cerebrospinal fluid pressure, cell count, and chemistries were within normal limits. The patient was transferred to Prasat Neurological Institute for definite diagnosis and proper management. The physical examination revealed bilateral lower extremity weakness (muscle strength 4/5) without paresthesia. Hyperreflexia was noted in the lower extremities. Babinski's sign was also positive. By counting vertebrae from whole spine screening, there was a degenerative bulging disc at the level of L4–L5 with spinal canal stenosis and compression of bilateral L5 traversing roots []. MRI of the thoracolumbar spine showed the spinal cord congestion at the level of T4 to the conus medullaris with subtle perimedullary flow voids along ventral and dorsal cord surfaces [Figure and ]. Furthermore, there was a curvilinear intradural flow void on T2-weighted image, identified below the conus medullaris. Contrast-enhanced MRA of the thoracolumbar spine demonstrated an enlarged intradural vessel in the midline location extending from the lower lumbar level to the conus medullaris, probably the vein of the filum terminale [], corresponding with the curvilinear flow void on MRI. Spinal angiography demonstrated SDAVF at the level of L4–L5, probably located on the right L5 nerve root sleeve, which is supplied by the right iliolumbar artery originating from the internal iliac artery with cranial drainage into the dilated vein of the filum terminale. The artery of Adamkiewicz arose from the right T8 intercostal artery. Endovascular treatment with NBCA through the right iliolumbar artery was successfully performed to fill in the arterial feeder and fistulous site but fail to reach the proximal vein []. Postembolization angiography of the internal iliac and iliolumbar arteries revealed complete obliteration of the fistula. The patient had gradually improved and was sent back to the local hospital for further physiotherapy. Four months later, he returned and was readmitted to our institution with gait disturbance with the deterioration of clinical symptoms. Follow-up MRI and MRA of the lumbosacral spine revealed unchanged long segment of spinal cord congestion with the presence of SDAVF at the same level. One week later, the patient underwent decompressive laminectomy with obliteration of the intradural draining vein. The patient had significantly improved until being the ability to walk independently 2 weeks later. Spinal angiography, obtained 2 weeks after surgery, confirmed complete obliteration of the fistula []. MRI of the thoracolumbar spine, obtained 4 months after surgery, confirmed the resolution of spinal cord congestion [].
A 46-year-old male was admitted to our institute due to a history of progressive paraparesis for 2 weeks. Eight months earlier, he experienced severe left buttock pain radiating to left leg for 2 weeks. He was admitted to other private hospital and underwent discectomy L5-S1. Five months later, he suffered from right leg pain and urinary retention. He went back to the same private hospital and underwent revised surgery with spinal fusion L5-S1. Two weeks before hospitalization, he developed progressive paraparesis and constipation. He was unable to walk more than about 100 m. The patient went to another private hospital and was transferred to Prasat Neurological Institute for further investigation and proper treatment after performing MRI of the lumbosacral and thoracic spine. The neurological examination revealed the evidence of spastic paraparesis (muscle strength 3/5) and the lack of pinprick sensation below T10 level, impairment of proprioception, hyperreflexia, and presence of Babinski's sign in the lower extremities. The previous series of MRI of the lumbosacral and thoracic spine were retrospectively reviewed and revealed spinal canal stenosis and bilateral lateral recesses stenosis at L5-S1 level due to moderate diffuse annular disc bulging with moderate enlargement of facet joints and thickening of the ligamentum flavum []. There was an abnormal hyperintense T2 signal with patchy enhancement representing spinal cord congestion extending from the conus medullaris to the level of T4 with subtle perimedullary flow voids along ventral and dorsal cord surfaces [Figures and ]. Magnetic resonance (MR) myelography also showed “worm-like” appearance of the area from thoracic level to the conus medullaris []. MR angiography (MRA) of the thoracolumbar spine demonstrated early opacification of perimedullary venous plexus along anterior and posterior surfaces of spinal cord []. Furthermore, there was a curvilinear flow void, probably the dilated vein of the filum terminale, running from lower lumbar level to the conus medullaris []. Spinal angiography demonstrated SDAVF at the level of L5-S1, probably located on the left S1 nerve root sleeve, which is supplied by the left lateral sacral artery (LSA) originating from the internal iliac artery with venous drainage through the dilated radicular vein into the dilated vein of the filum terminale [Figure and ]. The artery of Adamkiewicz arose from the left L2 lumbar artery and left T9 intercostal artery. Transarterial embolization with N-butyl-cyanoacrylate (NBCA) through the left LSA was successfully performed with NBCA filling across the fistula into the proximal draining vein []. The patient had gradually improved until being the ability to walk independently 3 months later. His bowel and bladder controls had completely regained. Six months after the embolization, follow-up MRI of the thoracolumbar spine also confirmed completely regression of spinal cord congestion [].