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CC BY-NC-ND 4.0 · Asian J Neurosurg 2022; 17(01): 088-094
DOI: 10.1055/s-0042-1748791
Case Report

Remote Intramedullary Hemorrhage in the Thoracic Spinal Cord Secondary to a Perimedullary Arteriovenous Fistula of the Distal End of Conus Medullaris Mimicking Filum Terminale Arteriovenous Fistula: A Case Report

Prasert Iampreechakul
1   Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
,
Anusak Liengudom
1   Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
,
Punjama Lertbutsayanukul
2   Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand
,
Somkiet Siriwimonmas
3   Department of Radiology, Bumrungrad International Hospital, Bangkok, Thailand
,
Sirintara Pongpech
4   Division of Interventional Neuroradiology, Department of Radiology, Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand
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Abstract

Perimedullary arteriovenous fistulas (PMAVFs) of the conus medullaris are rare and usually manifest with progressive myelopathy secondary to venous congestion resulting from retrograde arterialization of the draining vein into the spinal cord. We present a rare case of conus PMAVF presenting with remote intramedullary spinal cord hemorrhage in the thoracic cord. A 37-year-old woman was transferred to our institute due to sudden severe pain in the left lower leg and weakness of the lower extremities following progressive paresthesia of the lower extremities. Magnetic resonance imaging of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T6 with intramedullary hemorrhage at the level of T8–9 on the left side of the spinal cord. There were abnormal serpiginous intradural flow voids along the anterior surface of the spinal cord extending from the level of L2 to the lower cervical with venous varix at the level of T8–9, probably being the source of hemorrhage. Spinal angiography confirmed conus PMAVF at the distal end of the conus medullaris supplied by the sulco-commissural artery arising from the enlarged anterior spinal artery originating from the left T11 intercostal artery with cranial drainage through the dilated anterior spinal vein into the tortuous perimedullary veins up to the lower cervical level. The patient underwent successful endovascular treatment with N-butyl cyanoacrylate and had gradually improved until being ability to walk independently without residual pain of the left lower leg. We speculated that an increased venous flow into a varix may be considered an important risk factor of hemorrhage.

Keywords

type IV spinal cord arteriovenous malformations - perimedullary arteriovenous fistula - conus medullaris - intramedullary hemorrhage - filum terminale arteriovenous fistula

Authors' Contribution

P.I. contributed to the concepts, design, literature research, data acquisition, manuscript preparation, and manuscript review. A.L. contributed to the clinical studies and is a guarantor. P.L. contributed to the concepts, clinical studies, and data acquisition. S.S. is a guarantor. S.P. contributed to definition of intellectual content, data analysis, and manuscript editing.


Patient Consent

The patient has given consent to be enrolled and have her data published.


Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.




Publication History

Article published online:
01 June 2022

© 2022. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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