Perfusion-weighted MRI of spinal dural arteriovenous fistula

A 72-year-old woman was admitted with rapidly progressive paraplegia and sphincter disturbance. T2-weighted images of the thoracic spine showed intramedullary high signal with flow voids suggesting dilated medullary veins. Conventional spinal angiography demonstrated a dural arteriovenous fistula draining into perimedullary veins. Perfusion-weighted MRI demonstrated a prolonged mean transit time and increased blood volume in the high-signal area. The loss of normal perfusion gradient and venous hypertension and were thought to produce these differences. The time-to-peak was almost identical in the high-signal and isointense areas, although the bolus of contrast medium arrived earlier in the former. Arteriovenous shunting was thought to cause faster inflow. These changes may have resulted in increased blood volume in the spinal cord. The high signal has been attributed to oedema due to venous congestion, but there has been no histological confirmation. Perfusion MRI in this case supports this hypothesis.