Intramedullary hemorrhage from a thoracolumbar dural arteriovenous fistula

Background contextSpinal dural arteriovenous fistulas (AVFs) are acquired lesions presenting typically with neurologic deficits secondary to chronic congestive myelopathy. The low-flow and low-volume nature of these lesions makes hemorrhage very unlikely, and intramedullary hemorrhage caused by thoracolumbar dural AVFs is exceedingly rare.PurposeThe purpose of this study was to report a case of intramedullary hemorrhage caused by a thoracolumbar dural AVF.Study design/settingThe study design included a case report and review of literature.MethodsA case of intramedullary hemorrhage from a thoracolumbar dural AVF was reported, and the literature regarding hemorrhagic presentations of dural AVF was reviewed.ResultsA 66-year-old woman presented with a sudden onset of abdominal pain, paraplegia, sensory loss below the costal margins, and urinary retention. Magnetic resonance imaging scan showed intramedullary hemorrhage with abnormal flow voids raising suspicion of an intramedullary AV malformation. However, subsequent selective spinal angiography demonstrated a spinal dural AVF fed by the T7 intercostal artery and a varix within the draining vein. Complete obliteration of the dural AVF and the varix was achieved via embolization. As far as we are aware, there are only two other similar cases in the literature. Literature review revealed that presentation of thoracolumbar dural AVFs with hemorrhage is frequently associated with accelerated venous flow and the presence of a venous varix.ConclusionsAlthough very unusual, a spinal dural AVF may present with intramedullary hemorrhage, and hemorrhage in such conditions may be associated with an accelerated venous flow and the presence of a venous varix.