PMC6928661_01
Sagittal magnetic resonance imaging with (A) T2 spin echo (TSE) sequence reveals hypersignal of the spinal cord from T6 to the terminal cone (arrows) and flow voids behind the spinal cord that are (B) enhanced with gadolinium injection. The hypersignal of the spinal cord on TSE sequence corresponds to chronic hypoxic congestive myelopathy attributable to venous hyperpressure hindering venous return and caused by an arteriovenous shunt in spinal cord vascularization. The arrows in views A and B correspond to congested small venous vessels that are hard to visualize because they are quite thin.
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A second spinal cord MRI including a specific T2 spin echo sequence showed hypersignal of the spinal cord from T6 to the terminal cone that was associated with abnormal flow voids behind the spinal cord (Figure 1A). Flow voids were enhanced after an injection of gadolinium (Figure 1B).
Images from the (A) first and (B to F) second medullar angiographies performed on the patient. During the first angiography, the end of the anterior artery injection was visible (A, dark arrow), but the venous return of the spinal cord could not be visualized because it was slowed by a dural arteriovenous fistula (A, white arrow). During the second angiography, an uncommon vessel on T4 left level was visualized (B), draining in the spinal vein (C) and corresponding to the dural arteriovenous fistula. Endovascular treatment was performed by catheterization (D, black arrow) of the fistula point (D, white arrow). Injection of the embolic agent (E, white arrow) resulted in the disappearance of the dural arteriovenous fistula (F, black arrow).
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As a result, no significant abnormalities were detected (Figure 2A). A second medullar angiography performed by an experienced neuroradiologist allowed definite diagnosis of a left T4-level spinal dural arteriovenous fistula (Figures 2B and 2C). In the absence of anesthetic, vascular anatomic, and technical contraindications, endovascular treatment by embolization of the fistula point was successfully performed during the angiography (Figures 2D, 2E, and 2F).