PMC4109166_01
T2-weighted MRI of the spine: (a) midline sagittal image showing edema of the conus medullaris; (b) parasagittal image on the left showing engorged perimedullary veins (arrow). This finding is typical for SDAVF
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F1
Magnetic resonance imaging (MRI) of the spine showed marked edema and patchy contrast agent enhancement of the spinal cord from the T7 level to the conus medullaris, and enlarged perimedullary veins predominantly on the left side [Figure 1].
Digital subtraction angiography (DSA) of the left L2 artery in anterior-posterior projection showing a dural arteriovenous fistula (lower arrow) at the left foramen L2-L3 and the AA (upper arrow: note this artery's vertical course and typical hairpin curve into the descending branch)
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F2
Spinal angiography revealed an SDAVF in the left L2-L3 intervertebral foramen, fed by a branch from the second lumbar segmental artery (L2) on the left [Figure 2].
(a) Superselective angiography via the microcatheter at the fistula just before embolization; (b) DSA of the left lumbar artery after fistula embolization showing intact AA
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F3
On spinal angiography, the same SDAVF as before was visualized, still intact, and the AA branched off the same artery about 0.5 cm proximal to the fistula site [Figure 3a]. A microcatheter (UltraFlow 1.5 F, used with guidewire Mirage, both from Micro Therapeutics, Inc., Irvine, CA, USA) was navigated into the fistula just distally to the origin of the AA [Figure 3a]. The microcatheter was removed and final angiography through the guide catheter showed adequate flow to the ASA and no remaining SDAVF [Figure 3b].
T2-weighted MRI of the spine: (a) midline sagittal image showing less-intensive swelling but persistent edema signal on the conus medullaris; (b) parasagittal image on the left showing dilated perimedullary veins indicative of persistent SDAVF
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F4
Since the latest MRI also showed clearly dilated perimedullary veins on the left side [Figure 4], we decided to perform a new spinal angiography.
(a) DSA of the left L2 artery showing a dural arteriovenous fistula at the left foramen L2-L3 and the artery of the lumbar enlargement. (b) Superselective DSA via the microcatheter at the origin of the AA. (c) Superselective DSA via the microcatheter at the arteriovenous shunt just before embolization. (d) DSA of the left L2 artery after fistula embolization showing intact AA
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F5
Catheterization of the left L2 segmental artery was achieved using a 5 F catheter, and angiography revealed the artery of the lumbar enlargement and a persistent SDAVF arising from the same segmental artery [Figure 5a]. A microcatheter was navigated into the lumbar artery and superselective angiography done with the microcatheter just proximal to the AA permitted to discern in detail the origins of two arterial branches - one branch leading to the AA and the previously embolized feeder (which remained closed) and another more lateral and caudal branch that fed the fistula [Figure 5b]. The SDAVF was catheterized through the newly identified feeder, and embolized using 0.3 ml glue (67% Glubran-2 in Lipodol) [Figure 5c]. Final angiography of the left L2 segmental artery showed preserved flow through the artery of the lumbar enlargement without any remaining arteriovenous shunt [Figure 5d].
(a, b) Follow-up MRI scan taken 68 months after the last embolization. Note substance reduction of the spinal cord with visible central canal and no evidence of medullary edema or dilated perimedullary veins
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F6