case_images: PMC11225421_01
case_images: 1.5 Tesla Magnetic resonance imaging of the whole spine obtained 2 weeks after initial symptom of progressive paraparesis. (a-d) Sagittal T2-weighted images of cervical, thoracic, and lumbar spine show abnormal hyperintensity, representing spinal cord edema of the whole spinal cord. There are disc herniation and spinal stenosis at the level of C3-4, C4-5, C5-6, and C6-7.
case_images: SNI-15-209-g001.jpg
case_images: PMC11225421_01_SNI-15-209-g001.jpg
case_images: F1
case_images: No abnormal flow voids were reported in the radiological analysis [Figures 1 and 2].
case_images: 1.5 Tesla Magnetic resonance imaging of spine obtained 2 weeks after initial symptom of progressive paraparesis. (a) Sagittal contrast-enhanced T1-weighted image of cervicothoracic spine shows patchy enhancement of spinal cord. (b, c) Axial T2-weighted images of T6 and T9 levels reveal spinal cord edema with sparing of peripheral white matter.
case_images: SNI-15-209-g002.jpg
case_images: PMC11225421_01_SNI-15-209-g002.jpg
case_images: F2
case_images: No abnormal flow voids were reported in the radiological analysis [Figures 1 and 2].
case_images: 3 Tesla Magnetic resonance imaging of the whole spine obtained 1 month later. (a, b) Sagittal and (c, d) coronal 3D T2-SPACE images of cervicothoracic and thoracolumbar spine reveal the progression of venous congestion extending from lower brainstem to conus medullaris with subtle perimedullary flow voids (denoted by arrowheads in figure 3a). There are disc herniation and severe spinal stenosis at the level of C3-4, L3-4, and L4-5. SPACE: Sampling perfection with application-optimized contrasts using different flip angle evolution.
case_images: SNI-15-209-g003.jpg
case_images: PMC11225421_01_SNI-15-209-g003.jpg
case_images: F3
case_images: Tesla scanner and 3D T2-weighted sampling perfection with application-optimized contrasts using different flip angle evolution (SPACE) conducted 1 month after the initial symptoms emerged showed the spinal cord edema extending up to the lower brainstem, with subtle perimedullary flow voids at the thoracic level. The imaging also confirmed severe spinal stenosis at L2-3 and L3-4 levels due to disc herniation and ligamentum flavum thickening [Figure 3].
case_images: (a) Coronal and (b) sagittal maximum intensity projection images from contrast-enhanced magnetic resonance angiography of the whole spine demonstrate dilated and tortuous veins mainly along the anterior surface of the spinal cord extending from the conus medullaris to the cervical level, suspecting left-sided spinal dural arteriovenous fistula at lower thoracic level.
case_images: SNI-15-209-g004.jpg
case_images: PMC11225421_01_SNI-15-209-g004.jpg
case_images: F4
case_images: DAVF at the lower thoracic level [Figure 4]. Despite whole spinal angiography, the precise location of the fistula remained unidentified.
case_images: (a) Anteroposterior view of the left vertebral artery (VA) injection reveals the left dural arteriovenous fistula of craniocervical junction supplied by the radiculomeningeal branch (black arrowheads) of left VA from C1 level with draining veins extending rostrally to the medulla, and caudally to the cervical cord (white arrowheads) through dilated left lateral medullary vein. (b) Anteroposterior, (c) posteroanterior, and (d) lateral views of 3D reconstruction images of the left VA clearly demonstrate an enlarged and tortuous anterior spinal vein (white arrowheads).
case_images: SNI-15-209-g005.jpg
case_images: PMC11225421_01_SNI-15-209-g005.jpg
case_images: F5
case_images: This fistula was supplied by the radiculomeningeal branch of the left vertebral artery at the C1 level, with draining veins extending to the medulla and the entire spinal cord through the dilated left lateral medullary vein [Figure 5].
case_images: (a) Intraoperative photograph during surgery on the right lateral decubitus position after opening the dura. The proximal draining vein (green asterisk) is identified after the dissection of the first denticulate ligament. (b) After coagulation and disconnection of the draining vein, intraoperative indocyanine green angiography confirms the absence of fluorescent flow through the draining vein.
case_images: SNI-15-209-g006.jpg
case_images: PMC11225421_01_SNI-15-209-g006.jpg
case_images: F6
case_images: The vertebral artery and proximal draining vein were identified, and the proximal draining vein's disconnection was confirmed with intraoperative indocyanine green angiography, which showed no fluorescent flow post-coagulation [Figure 6].
case_images: (a) Anteroposterior view of the left vertebral artery injection obtained 2 weeks after surgery confirms complete obliteration of the fistula. (b) Coronal maximum intensity projection image from contrast-enhanced magnetic resonance angiography of the vertebrobasilar system obtained 4 months after operation also reveals no residual fistula.
case_images: SNI-15-209-g007.jpg
case_images: PMC11225421_01_SNI-15-209-g007.jpg
case_images: F7
case_images: The patient's postoperative recovery was smooth, and follow-up angiography 2 weeks later confirmed the complete elimination of the fistula [Figure 7a]. Further, MRA of the left vertebral artery and MRI of the entire spine 4 months post-surgery showed complete resolution of venous congestion and no recurrence of the fistula [Figures 7b and 8].
case_images: 3 Tesla Magnetic resonance imaging obtained 4 months after surgery. Sagittal T2-weighted images of (a and b) cervical, (c) thoracic, and (d) lumbar spine reveal complete resolution of venous congestion and disappearance of abnormal flow voids.
case_images: SNI-15-209-g008.jpg
case_images: PMC11225421_01_SNI-15-209-g008.jpg
case_images: F8
case_images: Further, MRA of the left vertebral artery and MRI of the entire spine 4 months post-surgery showed complete resolution of venous congestion and no recurrence of the fistula [Figures 7b and 8].