Paraspinal Arteriovenous Fistula Presenting With Subarachnoid Hemorrhage and Acute Progressive Myelopathy -Case Report-

Abstract

A 60-year-old man presented with paraspinal arteriovenous fistula (AVF) manifesting as subarachnoid hemorrhage (SAH) and acute progressive myelopathy. The patient presented with sudden onset of low back pain and paraparesis. Spinal magnetic resonance imaging revealed a vascular malformation on the lumbar spinal canal. Three-dimensional computed tomography angiography demonstrated a paraspinal AVF in the sacral ventral pelvis. The clinical symptoms were progressing rapidly, so transarterial embolization and surgical drainage ligation were performed. Paraspinal AVF may present with SAH and cause acute progressive myelopathy. Prompt examination and treatment are necessary.

MRI and MRA of spinal cord arteriovenous shunts

“…These shunts can be responsible for a venous myelopathy, either by congestion, if the shunt drains towards perimedullary veins, or by compression of the cord, if it drains into a venous ectasia that will, because of its pulsatility, erode the bony structures and penetrate inside the spinal canal. Paraspinal shunts can lead to cardiac failure in the neonatal population: the veins may rupture and create subarachnoid hemorrhages (45) or epidural hematomas (46). MRI and MRA detect these lesions in the form of dilated vessels located outside the spine.…”

Paraspinal arteriovenous fistula: Stuttgart classification based on experience and a review of the literature

“…Our literature search revealed only four patients, who suffered subarachnoid hemorrhage from a spontaneous PAVS. [13][14][15] Traumatic paraspinal AV shunts Traumatic PAVSs are caused or associated with a regional trauma of different severity. [15][16][17][18] Most often, traumatic PAVSs are located at the cervical level and are shunts between the vertebral artery and the paraspinal venous plexus or the jugular veins.…”

“…The latter could be a result of venous stenosis, pouches or thrombosis due to longstanding high-flow shunts. 14,26 Compressive myelopathy, isolated nerve root compression or infrequently steal of blood flow with highoutput cardiac failure are possible clinical symptoms, however, there is no classical presentation. 3,10,14,26,27,51,52 Congenital PAVSs often cause a murmur as the only symptom, especially before the age of 10.…”

“…14,26 Compressive myelopathy, isolated nerve root compression or infrequently steal of blood flow with highoutput cardiac failure are possible clinical symptoms, however, there is no classical presentation. 3,10,14,26,27,51,52 Congenital PAVSs often cause a murmur as the only symptom, especially before the age of 10. 53 Therefore, the need for treatment in this subgroup of PAVSs is discussed controversial, especially because the natural course of this rare entity is unknown and epidural venous engorgement occurs infrequently.…”