1230 - Paraplegia in the Setting of Thoracic Dural Arteriovenous Fistula

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

ER

Erick Rosenvall, MD

Resident
ECU Health Medical Center
Greenville, North Carolina, United States

Co-Author(s)

RM

Raymundo Millan, MD

Attending Physician
ECU Health
Greenville, North Carolina, United States
EZ

Evan Zeldin, MD

Clinical Assistant Professor
University of Cincinnati
Cincinnati, Ohio, United States
BB

Benjamin Buterbaugh, DO

Resident
ECU Health Medical Center
Winterville, North Carolina, United States

Presenter(s)

CC

Cole Carter, DO

Resident
ECU Health Medical Center
Greenville, North Carolina, United States

Case Diagnosis: 71-year-old male with paraplegia secondary to thoracic dural arteriovenous (AV) fistula

Case Description: Patient presented with a history of nine months of leg weakness presented with acute paraplegia. Patient initially developed acute back pain with associated lower extremity weakness nine months prior. He underwent a lumbar spine MRI revealing only arthritic changes and an EMG/NCV showing a neuropathic process involving the quadriceps. Conservative management commenced; however, shortly after an unrelated biopsy procedure, the patient developed sudden bilateral lower extremity paralysis.On admission, MRI of thoracic and lumbar spine revealed diffuse intramedullary cord edema from T6 through the conus consistent with a spinal dural AV fistula confirmed by diagnostic angiogram. Patient underwent surgical resection and thoracic laminectomies. The spinal cord injury was scored as a T11 ASIA B.

Discussions: Spinal dural AV fistulas are the most commonly encountered vascular malformation of the spinal cord. They commonly affect elderly men and are classically found in the thoracolumbar region. Arterial blood from a radiculomeningeal artery enters a radicular vein located inside the dura mater close to the spinal nerve roots. Eventually, this leads to decreased venous drainage leading to venous congestion causing chronic hypoxia and progressive myelopathy. Initial symptoms of venous congestion are nonspecific including difficulty climbing stairs, gait disturbances, or sensory symptoms such as paresthesias. On MR imaging, there is a characteristic combination of cord edema, perimedullary dilated vessels, and cord enhancement. Treatment includes occluding the shunting zones via embolization and prognosis is highly dependent on duration of symptoms before treatment and pretreatment disability.

Conclusions: Spinal dural AV fistulas are rare and underdiagnosed and if not treated properly, can lead to considerable morbidity with progressive spinal cord symptoms. It is imperative that physiatrists are aware of the initial nonspecific signs of spinal dural AV fistulas and order appropriate imaging to rule it out.