case_images: PMC10481793_01
case_images: (a) T1-weighted sequence, (b) T2-weighted sequence, and (c) post-gadolinium T1-weighted sequence - initial magnetic resonance imaging at a local hospital, showing intramedullary edema at T9-10 and T12 levels and a mildly dilated vessel at the cauda equina level (white arrow) without perimedullary vein enlargement. (d) Contrast-enhanced computed tomography image at our hospital, demonstrating a dilated vessel in the right first sacral foramen (black arrow). (e and f) Right internal iliac artery angiograms, showing sacral arteriovenous fistula supplied by the right lateral sacral artery. (g and h) Intraoperative photos showing an arterialized vein (white arrows) along the S1 nerve root visualized early by the indocyanine green without other shunt vessels. (i) Magnetic resonance imaging 5 months after surgery, showing extinguished intramedullary edema.
case_images: SNI-14-295-g001.jpg
case_images: PMC10481793_01_SNI-14-295-g001.jpg
case_images: F1
case_images: The spinal MRI showed two separate levels of spinal cord edema at the T9-10 and T12 levels that were slightly enhanced with contrast-enhanced [Figures 1a-c]. The CTA documented a dilated vessel extending from the right first sacral foramen to the conus medullaris [Figure 1d]. T8 to L5, revealed a sacral dural AVF with a "shunt point" on the right involving the S1 root (i.e., supplied by the right lateral sacral artery) [Figures 1e and f]. The slow flow passage of the intradural draining and right S1 radiculomedullary vein was consistent with a low-flow AVF. Following an L4-S1 laminectomy, intraoperative indocyanine green angiography revealed an arterialized "red vein" along the right S1 nerve root; no other shunting vessels were detected intradurally [Figures 1g and h]. Notably, the follow-up MR 4 months after surgery showed full resolution of the previously noted T9-10 and T12 cord edema [Figure 1i].