Abstract
Intradural spinal arteriovenous fistulas (sAVF) are spinal vascular lesions that usually manifest due to myelopathy or local symptoms caused by venous congestion and ischemia. In addition, perimedullary arteriovenous fistulas (PMAVF) in particular may rupture and cause subarachnoid or intramedullary hemorrhage along with relevant symptoms. Subarachnoid hemorrhage (SAH) can propagate into cranial space with clinically dominant symptoms and signs of typical aneurysmal intracranial SAH. The standard workup for cerebral SAH, after excluding an intracranial source of hemorrhage, is usually limited to a cervical spine MRI; therefore, thoracolumbar sources of hemorrhage can be missed, or their diagnosis may be delayed. Here we present a case of a pregnant patient who presented with cerebral SAH. The source of hemorrhage was not initially identified, leading to a presumptive diagnosis of benign pretruncal non-aneurysmal SAH. The correct diagnosis of spinal thoracolumbar PMAVF was revealed 2.5 months later due to the progression of local symptoms. While the diagnosis was being refined and endovascular treatment was being planned (but delayed due to pregnancy), there was a recurrence of intraconal hemorrhage followed by brainstem hemorrhage. This led to significant clinical deterioration. The PMAVF was then treated microsurgically and the patient experienced partial recovery.
Highlights
Intradural spinal arteriovenous fistulas are rare vascular lesions that usually present with progressive pain, radiculopathy, and myelopathy as a consequence of venous congestion
We present a case of a patient, in whom spinal arteriovenous fistulas (sAVF) manifested during pregnancy; the initial presentation was cranial subarachnoid hemorrhage (SAH)
The secondary presentation occurred in the postpartum period: first as intramedullary hemorrhage and subsequently as brainstem hemorrhage accompanied by neurological deterioration
Summary
Intradural spinal arteriovenous fistulas (sAVF) are rare vascular lesions that usually present with progressive pain, radiculopathy, and myelopathy as a consequence of venous congestion. Intramedullary hemorrhage or subarachnoid hemorrhage (SAH) may occur as well [1]. We present a case of a patient, in whom sAVF manifested during pregnancy; the initial presentation was cranial SAH. The secondary presentation occurred in the postpartum period (just as the diagnosis of thoracolumbar perimedullary AVF was made): first as intramedullary hemorrhage and subsequently as brainstem hemorrhage accompanied by neurological deterioration. Brain Sci. 2020, 10, 561 as the diagnosis of thoracolumbar perimedullary AVF was made): first as intramedullary hemorrhage and subsequently as brainstem hemorrhage accompanied by neurological deterioration
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