PMC4508730_01
Case 1. A: T2-weighted MR image 4 days after the onset showing high intensity lesions in the C3-C5 spinal cord with surrounding edema and in the C5 vertebral body (asterisk). No abnormal flow voids are recognized. B: T1-weighted MR image with contrast medium 5 days after the onset showing no enhanced lesion. C: Right vertebral angiogram 12 days after the onset showing an epidural AVF fed by the right C2 segmental artery (large arrow). Anterior spinal artery (small arrow) and posterior spinal artery (small open arrow) are patent. D: Left vertebral angiogram showing an epidural AVF mainly fed by the left C3 segmental artery (large open arrow). E, F (antero-posterior views, E: arterial phase, F: late venous phase) and G (lateral view): Transarterial embolization of the right C2 segmental artery was performed 12 days after the onset. Angiogram of the right C2 segmental artery showing epidural AVF draining into the right posterior internal vertebral venous plexus and descending to the right C3 with marked retention. Note that no perimedullary venous drainage is present. H: T2-weighted MR image 8 days after the embolization showing disappearance of the surrounding edema and persistent high intensity core. I: Four months later, transarterial embolization of the left C3 segmental artery was performed. Angiogram of the left C3 segmental artery showing the epidural AVF draining into the right posterior internal vertebral venous plexus, descending near to the left C4-5 intervertebral foramen, and ascending and then crossing the midline (not shown) with marked retention. Note that no perimedullary venous drainage is present. Arrowhead indicating the tip of the microcatheter, open arrowheads indicating the draining vein (E-G, I). AVF: arteriovenous fistula, MR: magnetic resonance.
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T2-weighted MR imaging 1 month after the operation revealed marked decrease of the spinal cord edema (Fig. 1J).
PMC4508730_02
Case 1. A: T2-weighted MR image 4 days after the onset showing high intensity lesions in the C3-C5 spinal cord with surrounding edema and in the C5 vertebral body (asterisk). No abnormal flow voids are recognized. B: T1-weighted MR image with contrast medium 5 days after the onset showing no enhanced lesion. C: Right vertebral angiogram 12 days after the onset showing an epidural AVF fed by the right C2 segmental artery (large arrow). Anterior spinal artery (small arrow) and posterior spinal artery (small open arrow) are patent. D: Left vertebral angiogram showing an epidural AVF mainly fed by the left C3 segmental artery (large open arrow). E, F (antero-posterior views, E: arterial phase, F: late venous phase) and G (lateral view): Transarterial embolization of the right C2 segmental artery was performed 12 days after the onset. Angiogram of the right C2 segmental artery showing epidural AVF draining into the right posterior internal vertebral venous plexus and descending to the right C3 with marked retention. Note that no perimedullary venous drainage is present. H: T2-weighted MR image 8 days after the embolization showing disappearance of the surrounding edema and persistent high intensity core. I: Four months later, transarterial embolization of the left C3 segmental artery was performed. Angiogram of the left C3 segmental artery showing the epidural AVF draining into the right posterior internal vertebral venous plexus, descending near to the left C4-5 intervertebral foramen, and ascending and then crossing the midline (not shown) with marked retention. Note that no perimedullary venous drainage is present. Arrowhead indicating the tip of the microcatheter, open arrowheads indicating the draining vein (E-G, I). AVF: arteriovenous fistula, MR: magnetic resonance.
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F1
T2-weighted MR imaging 1 month after the operation revealed marked decrease of the spinal cord edema (Fig. 1J).
Case 2. A: T2-weighted MR image 2 days after the onset showing marked spinal cord swelling and high intensity lesions in the C1-C7 spinal cord with low intensity lesions. No abnormal flow voids are recognized. B: Right vertebral angiogram 11 days after the onset showing an epidural AVF fed by the right C4 segmental artery draining into the right anterior internal vertebral venous plexus with perimedullary venous drainage. C-E: Serial angiograms of the right C4 segmental artery showing early filling of the anterior spinal artery (arrowheads) supplied by the radiculomedullary artery (C), and then an epidural AVF draining into the right anterior epidural venous plexus and ascending to the anterior spinal vein (D, E: open arrowheads). Note the diamond shape of the anterior spinal artery (D: dotted circle) and a connection with the epidural veins (E: arrow) and perimedullary veins of the cranio-cervical junction (E: open arrow). F: T1-weighted MR image 24 days after the onset showing high intensity lesion coinciding with the low intensity lesion on the T2-weighted image. AVF: arteriovenous fistula, MR: magnetic resonance.. Case 2. G: Axial T2* MR image at the C4 level 24 days after the onset showing a low intensity lesion indicating hemorrhage. H: Operative photograph showing intradural draining veins (white arrow) ascending along the right C4 ventral nerve root and the radiculomedullary artery (asterisk) connecting with the anterior spinal artery. I: Post-operative angiography showing disappearance of the perimedullary venous drainage and faint residual fistula of the epidural space. J: T2-weighted MR imaging 1 month after the operation showing marked decrease of the spinal cord edema. AVF: arteriovenous fistula, MR: magnetic resonance.
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Abnormal signal voids were not recognized (Fig. 2A). Right vertebral angiography demonstrated an AVF at the C3-C4 levels in the right anterior epidural space, mainly fed by the right C4 segmental artery, and draining into the right anterior internal vertebral venous plexus with perimedullary venous drainage (Fig. 2B). Transarterial embolization of the right C4 segmental artery was performed 11 days after the onset (Fig. 2C-E). T2-weighted imaging (Fig. 2F). T2* MR imaging at the C4 level showed a low intensity lesion indicating hemorrhage (Fig. 2G). The intradural draining veins ascending along the right C4 ventral nerve roots and the radiculomedullary artery connecting with the ASA were identified (Fig. 2H), and the draining veins were coagulated. Postoperative angiography showed disappearance of the perimedullary venous drainage and faint residual fistula of the epidural space (Fig. 2I).