Spinal Epidural Arteriovenous Fistula with Double Perimedullary Reflux

Abstract

The most common vascular malformation of the spine is spinal dural arteriovenous fistulae which account for around 70% of vascular malformation of the spine. These have been recently classified as "lateral epidural" shunts given their location along the lateral nerve root sleeves 1 . According to this classification, the ventral epidural AV shunts that drain into the ventrally located epidural venous plexus are usually asymptomatic, which has been previously attributed to the presence of an anti-reflux mechanism within the dural sleeves that prevents retrograde flow of the arterialized blood into radicular or perimedullary veins 2 .There are a few case reports in the literature that describe the rare occurrence of a shunt of the ventral spinal epidural space being redirected via a radicular vein towards the perimedullary veins resulting in venous congestion of the cord 3 . In the reported cases, a single radicular vein was rerouting the blood from the epidural plexus towards the spinal cord.Herewith, we report a patient with an epidural arteriovenous shunt with retrograde drainage into perimedullary veins via two radicular veins at two different levels, leading to the classic clinical and magnetic resonance imaging (MRI) findings of venous congestion of the spinal cord. To the best of our knowledge, this is the first description of two separate radicular veins being present to reroute the blood from the epidural venous plexus towards the spine. CASE REPORTA 68-year-old gentleman presented with a two month history of progressive paraparesis and paraesthesia. At the time of admission he was unable to walk being wheel chair bound since two weeks before admission. He had lost control of sphincter functions two weeks prior to admission. No further deficits were detected. His past history was significant with diagnosis of hepatocellular carcinoma one year prior to this event for which he declined any treatment.On MRI, the thoraco-lumbar spinal cord was slightly swollen with T2-hyperintensity and T1 hypo-to iso-intensity (Figure a). Post contrast T1 weighted images showed pronounced diffuse enhancement of the lower thoraco-lumbar spinal cord with the enhancement being more pronounced in the lower part of the cord including the conus medullaris (Figure b). Serpentine perimedullary hypointensities were present on T2-weighted studies which showed enhancement on contrast-enhanced T1-weighted images, indicating perimedullary dilated veins posterior and anterior to the spinal cord (Figure a, b). No intramedullary nidus was detected. ATECO MR angiogram was non-conclusive in localizing the level of the fistula. However a THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES 239 Spinal Epidural Arteriovenous Fistula with Double Perimedullary Reflux Jai Jai Shiva Shankar, Karel terBrugge, Timo KringsCan J Neurol Sci. 2012; 39: 239-241 BRIEF COMMUNICATIONSlarge venous pouch, perimedullary dilated veins and a suspicious prominent segmental artery was seen on the multi-phase computed tomography (CT) scan of the abdomen performed for the as...

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