Successful embolization of an upper cervical spinal dural fistula despite anterior spinal artery anastomosis

A female in her 40s presented with classic symptoms of subarachnoid hemorrhage and limited mobility of the bilateral upper extremities. Imaging demonstrated a minor amount of subarachnoid blood, and a follow-up computed tomography angiogram revealed a spinal dural arteriovenous fistula (SDAVF) located at C2-3. The C2-3 radicular artery proximal to the fistula feeder anastomosed with the anterior spinal artery, challenging the safety of embolization. However, surgical treatment of the SDAVF would require a suboccipital craniotomy due to its proximity to the foramen magnum, so possible embolization based on lidocaine provocative test results was decided upon. Neurologic examination of the patient following lidocaine provocative testing suggested that embolization could be performed safely. Glue embolization was successfully performed, and the patient awoke without complications. Subsequent imaging revealed no filling of the medullary vein that previously drained the fistula.