PMC8247718_01
(a) Sagittal T2-weighted MR image shows high signal intensity and edematous changes in the spinal cord (arrowhead). Enlarged perimedullary veins are depicted anterior and posterior to the spinal cord (arrows). (b) Sagittal enhanced T1-weighted MR image shows an intraosseous fistula in the Th12 vertebral body. (c) Axial T1-weighted Gd-enhanced VIBE MR image shows a hyperenhanced cavity (arrowhead) in the Th12 vertebral body and the epidural venous pouch (arrow). (d) Sagittal enhanced CT scans show the previous Th12 and L1 compression fracture, and longitudinally enlarged perimedullary veins. (e) Axial enhanced CT scans show a hyperenhanced cavity (arrowhead) in the Th12 vertebral body and the epidural venous pouch (arrow).
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F1
On magnetic resonance (MR) imaging [Figure 1a-c], high signal intensity was present in the lower portion of the spinal cord, and serpentine perimedullary edema was present below the mid-thoracic level as well as minimally enlarged veins around the conus medullaris. A computed tomography (CT) scan showed the previous Th12 and L1 vertebral compression fracture, a venous pouch in the Th12 fractured vertebral body, and dilated perimedullary veins [Figure 1d and e].
Selective spinal angiography of the dorsal somatic branch (white arrow) of the left Th11 (a) and the right Th12 (b) segmental artery reveals an epidural arteriovenous fistula (white arrowhead) with an epidural venous pouch (black arrowhead) draining through the intradural vein into the perimedullary vein (black arrows). (c) 3D fusion image merged with spinal angiography from the left Th11 and right Th12 segmental arteries shows the segmental artery (red), feeders (orange), epidural venous pouch (green), drainers (purple), and perimedullary vein (pink).
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F2
Th11 segmental artery with intraosseous fistula tracts directly connecting to the epidural venous pouch, and the right Th12 segmental artery directly shunted to the epidural venous pouch. The shunt flow gathered in the epidural venous pouch and drained with reflux into the perimedullary vein through an intradural vein [Figure 2].
Transarterial embolization with 12.5% heated NBCA was performed through the dorsal somatic branch of the right Th12 segmental artery (a), and complete obliteration of the fistula from the Th12 segmental artery was obtained (b). Subsequently, transarterial embolization with NBCA was performed through the dorsal somatic branch of the left Th11 segmental artery (c and d), and total obliteration of the fistula was obtained (e).
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F3
Th11 segmental artery was performed in the same manner. The final angiogram revealed complete obliteration of the fistula [Figure 3].
CT (a) after embolization shows the glue cast in the intraosseous fistula (arrow) in the Th12 vertebral body and the ventral epidural pouch (arrowhead). Six-month follow-up sagittal T2-weighted MR image (b) of the thoracolumbar spine reveals the disappearance of the perimedullary venous structures and normal spinal cord signal intensity.
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F4
No recurrence was observed 2 years after the treatment [Figure 4].