Case Study – Dural Arterio-Venous Fistula

A 71 year old lady presented with bilateral lower limb pain and progressive weakness and difficulty with independent ambulation.

 An MRI had been arranged prior to neurosurgical review.

 What is the diagnosis?

The final diagnosis of dural arterio-venous fistula or Type I spinal AVM was missed both by the referring GP and the radiologist.  The changes on the scan amount to oedema of the conus medullaris (subtle T2 weighted signal change) and serpiginous vascular flow voids on the dorsum of the cord.

 A branch of the radicular vessel off the aorta has become fistulous and created a connection with the draining veins of the spinal cord.  The now dilated veins are prominent on the MRI and reduction of the venous drainage of the spinal cord leads to the oedema.

 In the initial consultation, the patient was asked about her bowel habit and peri-anal sensation which had become sluggish and numb respectively, and repeated urinary tract infections in the history also pointed to her bladder dysfunction and urinary retention.

 An angiogram shows the tortuous vessels on the back of the spinal cord from a fistulous vessel at the T11 level.

 

At surgery, the connection between the venous drainage and the artery is closed down.

The “arterialised veins” on the dorsum of the spinal cord, with the dura open.

 

 

 

 

 

 

 

 

The arrow points to the fistulous vessel inside the dura.  This was cauterized and divided.

 

 

 

 

 

 

 

This patient has done well post-operatively and is recovering in rehab.  She needs to retrain her bladder and get back her mobility.

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