Dural fistula, case 1

Clinical history
This 47-year-old male complained of sensory and motor deficit of both lower limbs as well as troubles with micturition and bowel function for almost 5 months. Further, he developed lumbar pain radiating to the groin while micturating. Progressively, he also developed weakness in both lower limbs. At this time, MR was performed.

MR examination
Image 1: Sagittal T1WI. No major anomalies are seen on those images.
Image 2: Sagittal T2WI. On those pulse sequences, definite high signal abnormalities may be seen within the lower spinal cord and the conus. No abnormal vessels are suspected on the surface of the cord.
Image 3: Sagittal GdT1WI. After Gadolinium injection, definite enhancement occurs within the lower thoracic cord and conus.
Image 4: Axial T2WI. The high signal intensity areas are equally well seen and are confirmed on axial T2 weighted images.
Image 5: Finally, suspecting a dural fistula, MR myelography was performed. Abnormal vessels may definitely be identified. They are best seen on the native heavily T2 weighted coronal thin slices.

In conclusion
The diagnosis of dural fistula is most likely.

Images 6 - 7 - 8. Selective medullary arteriography.
Based on the MR examination, selective medullary angiography was performed. It confirmed a dural fistula fed by the left Th11 artery with perimedullary venous drainage.
Unfortunately, the artery of Adamckiewicz was arising from the same branch as the one feeding the fistula. This prevented any embolisation. For this reason, the patient was treated surgically.

Post-operative evolution
The patient noted improvement of the urinary problems but there was a persistent Brown-Sequard syndrome with right pyramidal syndrome and sensory disturbance of the left lower limb.

Search also:
- AVM, Dural fistulae

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