PMC7294149_01
Lumbar MRI with and without contrast shows mass effect along the right side of the spinal canal from T12 to L2 levels displaces the conus leftward (a). The subcentimeter triangular focus of enhancement at T12-L1 disc can be appreciated (b). The cauda equina shows deformity inferiorly surrounded by blood products in the spinal canal. No typical evidence of flow voids consistent with increased vascularity of spinal SDAVF. Lumbar spine digital subtraction angiography (DSA) shows a contrast injection into the right L1 lumbar segmental artery (c). DSA shows the same for the left L1 lumbar segmental artery (d). There is no evidence of vascular abnormality in any phase of filling or emptying of the radicular artery and vein. Intraoperative images show a radicular artery traveling intradurally and anastomosing with the venous system, as is evident of a spinal fistula (e). Isolated view of SDAVF radicular artery (f). Temporary occlusion of the fistulous artery for extended motor and sensory monitoring for changes (g). The fistulous artery is cauterized and cut (h).
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F1
The CT of the thoracic and lumbar spine revealed extensive increased density throughout the thoracolumbar spinal canal, consistent with acute hemorrhage. The magnetic resonance imaging confirming the subdural/subarachnoid location of the mostly right-sided hemorrhage (mostly T12-L2) anterior to the spinal cord extending from the L2 up to the T6-7 level. [Figure 1a and b]. A full diagnostic craniospinal angiogram was performed, including selective catheterization of T7-L3 radicular arteries [Figure 1c and d], which also failed to demonstrate any vascular lesion (e.g., no SDAVF). On opening the dura, a large, cylindrical, and well-organized subdural hematoma was encountered with blood products of varying chronicity these markedly distorted the spinal cord (e.g., right to left compression) [Figure 1e-h].