Slow-flow spinal epidural AVF with venous ectasias: two pediatric case reports

Abstract

We report the clinical and imaging findings in the cases of two children who initially presented with back pain related to epidural AVF in the cervicothoracic spine. Both lesions were of particular interest because of their exclusive epidural and paraspinal venous drainage and the presence of the prominent venous pouches in the epidural space. Angiography revealed that one was multifocal and of relatively slow flow. We think that these unusual features have important implications for treatment.

Fig 1.

Images from the case of patient 1, a 4-year-old girl who presented to an outside hospital with a history of nonradiating sharp upper thoracic back pain. A, Sagittal view fast spin-echo T2-weighted MR image. Dorsal epidural hematoma extending between the C4 and T2 levels results in compression of the spinal sac (arrows) but no abnormal intramedullary T2 hyperintensity. Relatively decreased T2 signal intensity in the C3–C6 intervertebral discs may be related to the neighboring epidural AVF and hematoma. B, Frontal view maximum intensity projection 2D time-of-flight MR angiogram shows an enlarged left thyrocervical trunk (arrow). C, Posteroanterior projection of a selective injection of the left costocervical artery (arrowhead) shows a fistula into a large epidural venous pouch (white arrow) that drains into the epidural and paravertebral venous plexuses (black arrows). D, Radiograph shows the cast of the liquid adhesive (arrows) within the venous pouch. E, Postembolization left costocervical angiogram shows that the dominant fistula is closed but that a separate small epidural fistula (black arrow) remains. The catheter tip is located at the left origin of the left costocervical trunk (white arrow). Reflux of contrast material results in opacification of the left vertebral artery (asterisk). Additional small epidural AVF were revealed when the right costocervical trunk was injected (not shown). F, Postoperative sagittal view fast spin-echo T2-weighted MR image shows enlargement of cervical dorsal epidural hematoma (arrows), with mild cord compression and new intramedullary T2 hyperintensity (arrowhead).

Fig 2.

Images from the case of patient 2, a 4-year-old boy who presented to an outside clinic with complaints of several days of episodic severe upper thoracic back pain and associated muscle spasm. A, Contrast-enhanced sagittal view T1-weighted MR image with fat saturation. A homogenously enhancing circumferential epidural mass can be seen from C7–T3 (arrows). No abnormal intramedullary signal intensity was seen on the T2-weighted MR images (not shown). Associated subtle widening of the anteroposterior diameter of the spinal canal suggests a long-standing vascular malformation. B, Left oblique lateral view maximum intensity projection from a dynamic contrast-enhanced MR angiogram (technique according to Farb et al [7]). Abnormal enhancing enlarged dural branches can be seen arising from the left supreme intercostal artery (arrowhead), with arteriovenous shunt surgery and enhancement of the large epidural venous sac (arrow). C, Posteroanterior view projection of selective injection of left supreme intercostal artery. Several large dural arteries feeding AVF (arrowheads) and large epidural venous pouch with drainage via left epidural venous plexus and internal jugular vein (arrows) can be seen.