Paraplegia in a chiropractic patient secondary to atraumatic dural arteriovenous fistula with perimedullary hypertension: case report

Foreman, Stephen M.; Stahl, Michael J.; Schultz, Gary D.

doi:10.1186/2045-709x-21-23

Cited by 8 publications

(7 citation statements)

References 14 publications

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“…This exceptionally rare type of DAVF can present with a wide array of symptoms due to the variable extent of venous congestive myelopathy. 10,11,17,19,24 The onset can either be sudden or gradual, making a solely clinical diagnosis impossible. 18,26,31 Therefore, clinicians confronted with such a lesion are frequently misdirected to a tentative diagnosis of brainstem and spinal cord infarction, Guillain-Barré syndrome, demyelination and inflammation, or-as in our case-a neoplasm.…”

Section: Discussionmentioning

confidence: 99%

Unilateral contrast-enhancing pontomedullary lesion due to an intracranial dural arteriovenous fistula with perimedullary spinal venous drainage: the exception that proves the rule

Roelz

Velthoven²,

Reinacher

et al. 2015

JNS

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Dural arteriovenous fistulas (DAVFs) are abnormal communications between dural arteries and dural venous sinuses, meningeal veins, or cortical veins. They account for 10%-15% of intracranial arteriovenous malformations.12,33 Grading of DAVF is based on the venous drainage pattern according to the classification schemes of Borden et al. and Cognard et al. 4,8 Venous cortical or perimedullary drainage and dilation are the hallmarks of high-grade DAVF and strongly correlate with increased risk of intracranial hemorrhage and nonhemorrhagic neurological deficit. The exact etiology of DAVFs is unknown. They are predominantly idiopathic, though they may also be congenital lesions or found in association with dural venous sinus thrombosis, trauma, previous craniotomy, and tumors. While spinal DAVF is an established cause of vascular myelopathy, intracranial DAVFs with perimedullary spinal venous drainage (Cognard Type V) are rare disorders and often represent a diagnostic and therapeutic challenge. They have been mainly described in case reports or small series that reported a typical clinical and radiological presentation of progressive myelopathy, central cord edema, and engorged perimedullary veins.Here, we report a case of an intracranial DAVF with exclusive perimedullary spinal venous drainage that presented initially with a very unusual MRI appearance suggestive of a right lateral brainstem neoplasm. After delayed diagnosis, the DAVF was completely occluded by transarterial embolization and the patient's symptoms gradually improved.abbreviatioNs DAVF = dural arteriovenous fistula; DSA = digital subtraction angiography; MRA = MR angiography. A large spectrum of possible diagnoses must be taken into consideration when a contrast-enhancing lesion of the pontomedullary region is found on MRI. Among these diagnoses are neoplastic, inflammatory, and infectious, as well as vascular pathologies. The authors report a rare case of an intracranial dural arteriovenous fistula (DAVF) with perimedullary spinal venous drainage (Cognard Type V) that initially presented as a unilateral contrast-enhancing pontomedullary lesion mimicking a brainstem neoplasm in a 76-year-old man. Following occlusion of the DAVF by transarterial embolization that resulted in clinical and radiological improvement, the fistula recurred 10 months later and was finally cured by a combined endovascular and surgical approach that resulted in complete occlusion. Clinical symptoms and MRI findings gradually improved following this treatment. A literature review on the MRI findings of Cognard Type V DAVF was performed. Centrally located medullary or pontomedullary edema represents the typical imaging finding, while unilateral edema as seen in the authors' patient is exceptionally rare. The hallmark imaging finding suggestive of DAVF consisting of perimedullary engorged vessels may not always be present or may only be very subtly visible. Therefore, the authors suggest performing contrast-enhanced MR angiography or even digital subtraction angiography in the ...

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Section: Discussionmentioning

confidence: 99%

Unilateral contrast-enhancing pontomedullary lesion due to an intracranial dural arteriovenous fistula with perimedullary spinal venous drainage: the exception that proves the rule

Roelz

Velthoven²,

Reinacher

et al. 2015

JNS

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“…There are a few published case studies that state that hyperextension from a chiropractic maneuver can result in a formation of a vertebral arteriovenous fistula. 1,3 Whether she has seen a chiropractor prior to hearing the whooshing sound has not been confirmed at the time of the carotid duplex study.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 In addition to those, there is another origin that has been documented, but not well discussed as a cause of a vertebral arteriovenous fistula formation: hyperextension in a chiropractic manipulation. [1][2][3] This case study discusses a vertebral arteriovenous fistula of a patient without a history of an invasive medical procedure or underlying genetic disorders.…”

Section: Introductionmentioning

confidence: 99%

An Unusual Suspect for a Traumatic Arteriovenous Fistula in the Left Vertebral Artery

Noh

2020

Journal for Vascular Ultrasound

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This case study discusses an unusual vertebral arteriovenous fistula of a patient with no history of an invasive medical procedure or underlying genetic disorders. The patient is a 54-year-old female with a history of tinnitus for 6 months behind the left ear prior to coming to the vascular laboratory. There was a connection between the left vertebral artery and the vertebral vein, which showed a mosaic pattern with a high velocity. The spectral Doppler waveform in the vertebral vein post the unintended anastomosis showed an arterialized venous Doppler waveform, confirming that the area of the interest was indeed an arteriovenous fistula. The image of the screening computed tomography performed on the same day did not show this connection or dilated venous system, possibly because of the small size of the fistula. A published literature suggests hyperextension as a possible suspect. There are a few test modalities that can identify an arteriovenous fistula, but ultrasound maybe the most desirable due to the fact that it does not involve an invasive procedure or a contrast dye. It is very important for a sonographer to learn the advanced information such as how to identify a true arteriovenous fistula with the analysis of Doppler waveform in the vein post the anastomosis. In doing so, it will increase the sonographer’s knowledge as well as promoting the field of ultrasound overall.

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“…We believe Edwards et al incorrectly cited our case report [ 2 ] as scientific evidence the literature contains “numerous prior cases of vertebral AVFs report induction by chiropractic manipulation.” Our case report made no such connection with spinal manipulation. In fact, we argued the opposite .…”

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confidence: 99%

Comment on “Vertebral Arteriovenous Fistula: An Unwelcome Thrill”

Foreman¹,

Stahl²

2018

Case Reports in Emergency Medicine

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Paraplegia in a chiropractic patient secondary to atraumatic dural arteriovenous fistula with perimedullary hypertension: case report

Cited by 8 publications

References 14 publications

Unilateral contrast-enhancing pontomedullary lesion due to an intracranial dural arteriovenous fistula with perimedullary spinal venous drainage: the exception that proves the rule

Unilateral contrast-enhancing pontomedullary lesion due to an intracranial dural arteriovenous fistula with perimedullary spinal venous drainage: the exception that proves the rule

An Unusual Suspect for a Traumatic Arteriovenous Fistula in the Left Vertebral Artery

Comment on “Vertebral Arteriovenous Fistula: An Unwelcome Thrill”

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