A 70-year-old gentleman presented with a 12-month history of progressive bilateral lower limb weakness and numbness. He also developed constipation and urinary retention over the two weeks preceding presentation. There was no history of fever, backache, trauma, weight loss, or cough. Medical history was significant for type-2 diabetes mellitus and hypertension. For these symptoms, he consulted multiple physicians at different hospitals and underwent three magnetic resonance imaging (MRI) of the spine, which the radiologists reported as cervical spondylosis, transverse myelitis, and cervical syrinx, respectively. He was managed with high-dose intravenous steroids (methylprednisolone 1000 mg daily for five days) with tapering oral steroids, multivitamins, and coenzyme Q but his weakness gradually worsened.\nOn neurological examination, higher mental functions were intact. Cranial nerves examination was within normal limits. Pupils were bilateral 3 mm in diameter with normal pupillary reflex to light and accommodation. The fundus examination was unremarkable. Muscle bulk and muscle tone were normal in all four limbs. Muscle strength was normal in upper limbs while it was reduced in the lower limbs bilaterally, with the Medical Research Council (MRC) grade of 3/5 in both proximal and distal muscle groups. Deep tendon reflexes were normal in all four limbs except the ankle reflexes, which were reduced (1+) bilaterally. Babinski’s reflex was present bilaterally. Pinprick sensations were reduced below the level of T7. Proprioception testing was abnormal in lower limbs bilaterally.\nAnother MRI of the spine was performed (Figure ). The T2-weighted MRI images revealed patchy edema in the spinal cord extending from the C4 vertebral body up to the conus along with vessel flow voids dorsally. These findings were suggestive of spinal dural arteriovenous fistula (SDAVF). Although these findings were also present in the previous MRI scans, they were missed on reporting.\nThe diagnosis of SDAVF was subsequently confirmed on digital subtraction angiography (Figure ) and the fistula was embolized using histoacryl glue and lipoidal mixture. He was stable post-procedure and his weakness improved (MRC grade 4/5) within the next 48 hours.
A 38-year-old woman was referred to our department because of dizziness. CT angiography demonstrated an incidental right duplicated VA originating from the right subclavian artery. Axial CT showed that the medial limb of the duplicated VA was located posteromedially to the right CCA and anteriorly to the vertebral transverse foramen. Sagittal CT revealed that the medial limb of the duplicated VA was located in close proximity to the CCA and internal carotid artery (). The patient was managed conservatively, and her dizziness improved.