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Perimedullary arteriovenous fistula was misdiagnosed as intervertebral disc herniation: A case report
Zhengbo Yuan1, Fengzhen Xiong, Zefu Li
1Department of Neurosurgery, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, Shandong, 256603, China.
Introduction:
Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction.
Patient Concerns:
The patient was a 58-year-old male who presented with both lower limbs numb with intermittent walking weakness, obvious at both ankles, and no obvious inducing and relieving factors. The local hospital considered the diagnosis of lumbar disc herniation after MR examination; he was treated with lumbar fixation and fusion.
Diagnosis:
After admission, a ce-MRA examination showed that the left spinal artery at the T10 level showed small branch blood vessels in the local area. The distal end was unclear, which seemed to be connected with the drainage vein of the spinal cord. The digital subtraction angiography (DSA) result indicated that the left intercostal artery of T10 sent the Adamkiewicz artery down to the level of L4, and an arteriovenous fistula was seen. The fistula was located at the lower edge of the L4 level and then drained to the upper premedullary vein to the level of T4 after a short descending. It was finally diagnosed as a perimedullary arteriovenous fistula.
Interventions:
It was cured by cutting the arteriovenous fistula in the spinal canal by indocyanine green-assisted angiography.
Outcomes:
we report a case of PMAVFS misdiagnosed as lumbar disc herniation with resection and internal fixation. In our hospital, the final diagnosis was a perimedullary arteriovenous fistula, which was cured by cutting off the arteriovenous fistula within the spinal canthus.
Conclusion:
Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction. It is hoped that this can provide warnings to more neurosurgeons and reduce the occurrence of misdiagnosis.
Insights
Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare condition often misdiagnosed. This case highlights successful surgical treatment after initial misdiagnosis as lumbar disc herniation.
Area of Science:
- Neurosurgery
- Vascular Neurology
- Spinal Cord Imaging
Background:
- Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation.
- Adult PMAVFs are typically small, low-flow, and present with progressive spinal dysfunction.
Observation:
- A 58-year-old male presented with progressive lower limb numbness and weakness, initially misdiagnosed as lumbar disc herniation.
- MR imaging was inconclusive, leading to lumbar fixation and fusion surgery.
Findings:
- Contrast-enhanced MR angiography (ce-MRA) revealed abnormal vasculature at T10.
- Digital subtraction angiography (DSA) confirmed a PMAVFS originating from the left T10 intercostal artery, involving the Adamkiewicz artery and draining into the premedullary vein.
- Surgical resection of the arteriovenous fistula was performed using indocyanine green-assisted angiography.
Implications:
- This case underscores the challenge of diagnosing spinal PMAVFS, emphasizing the need for advanced vascular imaging.
- Accurate and timely diagnosis is crucial to prevent misdiagnosis and inappropriate surgical interventions.
- Successful surgical intervention can lead to positive patient outcomes for spinal PMAVFS.
