PMC6935962_01
(a) Preoperative sagittal T2-weighted magnetic resonance images showing abnormal vessels as a flow void around the spinal cord and intramedullary hyperintensity. (b) T11 angiographic imaging demonstrating the relationship between anterior spinal artery, draining vein, pial artery, and arteriovenous (AV) shunt. (c) Preoperative high-resolution angiography showing anterior spinal artery, pial artery, AV shunt, and draining vein.
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F1
Angiographically, it was supplied by the anterior spinal artery [Figure 1a-c].
Preoperative 3D with an arrow showing images of laminectomy, anteroposterior view, lateral view, and 60  view with the arteriovenous shunt point.
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F2
(a) Intraoperative arrow image of cord rotation with shunting point and draining vein visible. (b) Intraoperative arrow image showing perimedullary arteriovenous fistula (pAVF) on the ventrolateral surface of the rotated cord with the ipsilateral dentate ligament. (c) Arrow image showing temporary clipping of proximal and distal anterior spinal artery (ASA) feeding the pAVF. (d) Arrow image of complete resection of pAVF and indocyanine green confirmation of the flow in the ASA.
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F3
There was a direct arteriovenous connection between the anterior spinal artery (ASA) and a thin-walled abnormal vein, and a duplication of the ASA for the segment harboring the fistula [Figure 3a and b]. Using (indocyanine green [ICG]) videoangiography, temporary clipping showed complete occlusion of the proximal and distal to the origin of the pial arterial feeders [Figure 3c]. The postclipping ICG confirmed the now isolated shunt, and the absence of flow through the fistula; it was then excised [Figure 3d].
Postoperative magnetic resonance imaging demonstrates complete resection of the perimedullary arteriovenous fistula and well preserved anterior spinal artery flow.
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F4
Six months later, it continued to show complete occlusion/resection of the pAVF [Figure 4].
Histopathology: Verhoeff Van Gieson stain, arrowhead shows abnormal vascular structures with smooth muscle and elastic fibers inside the blood vessel walls, the latest with variable thickens and vessel caliber, irregular intimal hyperplasia and hyalinized walls. Arrow shows the possible shunting areas.
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F5
The Verhoeff Van Gieson stain showed smooth muscle and elastic fibers inside the blood vessels that had variable wall thickening/ caliber that correlated with a pAVF [Figure 5].