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 36 year-old male with a history of dizziness and suspected cerebrovascular pathology was referred to our center for angiographic evaluation of carotid and vertebral arteries. He underwent multidetector 64-row computed tomography (MDCT) angiography. (GE: Optima660,2011, Tokyo, Japan60). Eighty-five milliliter of nonionic iohexolcontrast (Omnipaque, 350 mg I/ml, GE Healthcare, Shanghai, China) was injected at a rate of 5 ml/s by a power injector through the antecubital vein. The acquired images (slice thickness 0.625 mm) were further analyzed in a work station (GE: AW Volume Share 4) to generate volume-rendered (VR) and maximum intensity projection (MIP) images.\nThe left vertebral artery (LVA) had two separate limbs of origin []. The medial limb (2.2 mm in diameter at its origin) originated directly from the aortic arch in between the origins of left common carotid (LCCA) and left subclavian arteries (LSA) []. The lateral limb (2.4 mm in diameter at its origin) emanated from the LSA in its orthodox position and entered the foramen transversarium of C6 vertebra. Both the limbs united to form a single trunk at C5-C6 interval and the single trunk (3.2 mm in diameter) then entered C5 transverse foramen [Figures and ]. Both the limbs of the right vertebral artery (RVA) originated from the right subclavian artery (RSA) []. The medial limb (3.9 mm in diameter at its origin) originated from its orthodox position, whereas the lateral limb (2.4 mm in diameter at its origin) arose more posteriorly close to the origin of thyrocervical trunk. The lateral limb entered the C6 transverse foramen, but the medial limb entered the carotid space lying posteromedial to right common carotid artery (CCA) []. At the interval between the C4 and C5 vertebrae, both the limbs fused to form a single trunk (4.4 mm in diameter) which entered the C4 transverse foramen [Figures and ]. Further distal course of both vertebral arteries was normal and no cerebrovascular pathology could be detected.