Pure spinal intraosseous arteriovenous fistula: A case report

Spinal osseous arteriovenous fistula (AVF) is a rare disease with a characteristic angioarchitecture involving an intraosseous venous pouch (VP) of the vertebral body where the feeders are converging. Using spinal angiography alone, it is difficult to distinguish spinal osseous AVF from classical spinal epidural AVF (EDAVF) with fistulas in the epidural VP and bone erosion because both subtypes have an angiographically similar dilated VP appearance. Thus, spinal osseous AVF may be often misdiagnosed as spinal EDAVF. With advancing imaging techniques, it would be possible to determine the exact location of the fistula. Here, we present the case of a 37-year-old woman with a pure spinal thoracic osseous AVF and radiculopathy. She was diagnosed with spinal intraosseous AVF using high-resolution three-dimensional rotational angiography (3D-RA). The fistula was located in the Th1 lateral mass with a VP where multiple osseous feeders were converging. There was paravertebral venous drainage without intradural venous drainage. Transvenous embolization with Onyx and coils was performed through the azygos vein to the lateral epidural venous plexus, resulting in complete obliteration. This case suggests that 3D-RA reconstructed images are essential for accurate diagnosis and successful treatment of this condition. It is important to occlude only intraosseous VPs by accurate subtype diagnosis. Transvenous embolization is a treatment option for spinal intraosseous AVF with paravertebral epidural venous drainage.