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.
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.