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The Lengthy and Winding Highway: Thoracic Myelopathy Related With Occipitocervical Dural Arteriovenous Fistula.

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The Lengthy and Winding Highway: Thoracic Myelopathy Related With Occipitocervical Dural Arteriovenous Fistula.

World Neurosurg. 2017 Dec;108:998.e7-998.e16

Authors: Sao-Mai Do A, Kapurch J, Kumar R, Port J, Miller JW, Van Gompel JJ

Summary
OBJECTIVES: Spinal dural arteriovenous fistulas (DAVFs) have numerous shows. Magnetic resonance imaging (MRI) reveals spinal twine swelling in solely 45% to 74% of instances. We current an uncommon case of a 57-year outdated man with a craniocervical junction DAVF wherein the edema appeared within the thoracolumbar area, skipping the cervical spinal twine.
METHODS: A case report and literature evaluation from a tertiary referral heart are offered.
RESULTS: In our affected person, signs progressed over three months from low again and radicular ache to weak spot, saddle anesthesia, and urinary retention. MRI confirmed T2 hyperintensity from T3-Four to the conus medullaris. The outcomes from preliminary mind and backbone angiograms had been damaging. Repeated angiography with the affected person below anesthesia revealed a DAVF within the craniocervical junction composed of a cervical department arising from the best vertebral artery and getting into the nidus on the foramen magnum. A outstanding intradural draining vein prolonged inferiorly alongside the posterior facet of the cervical spinal twine. The affected person was taken to the working room, the place the extradural vertebral artery was dissected and a suboccipital craniectomy was carried out. After the dura was opened, the arterialized vein was visualized and clipped. Somatosensory evoked potentials and motor evoked potentials remained at baseline all through the occlusion. The dura and fistula had been eliminated en bloc, and the draining vein was confirmed to lose move on indocyanine inexperienced. Postoperatively, the affected person’s signs utterly resolved, and he skilled full power within the decrease extremities and perineal sensation. A evaluation of 19 instances of DAVF on the craniocervical junction with twine edema reveals that >90% contain the brainstem or cervical twine. Just one different affected person had an analogous “skip lesion,” wherein the twine edema first appeared within the thoracic twine.
CONCLUSIONS: This uncommon presentation highlights the significance of diagnostic persistence when unexplained twine findings are seen on MRI. Repeated angiography and the inclusion of proximal vascular lesions could also be thought-about within the analysis of remoted thoracic edema.

PMID: 28966151 [PubMed – indexed for MEDLINE]

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