Percutaneous intravertebral body embolization of a traumatic spinal epidural arteriovenous fistula with secondary perimedullary venous reflux. A case report

Abstract

Arteriovenous fistulas following vertebral fractures are probably very rare. We present a case with fistulous connection between arteries and veins within the fractured 12th thoracic vertebral body with retrograde venous drainage to perimedullary veins resulting in spinal venous hypertension and a cauda equina like symptomatology. Pre-treatment 3D CT enabled us to puncture the venous pouch within the vertebra and deposit glue in the vertebral fistula. The procedure led to a complete occlusion of the fistula and relief of pain and neurological symptoms.

Figure 1

A) Sagittal T2-weighted MRI shows a healed wedge fracture in Th12 (asterix), dilated basivertebral vein (arrow) and dilated perimedullary veins (arrowheads) as well as spinal cord hyperintensity. B) Coronal MRA frontal thin slice MIP shows dilated intradural veins (arrow).

Figure 2

A) Axial non-contrast CT image shows a channel inside the posterior part of TH 12 (arrowheads) converging towards the basivertebral vein (arrow). B) Axial contrast enhanced CT shows that the right part of the channel is filled with contrast (arrow) and there are dilated intraspinal veins.

Figure 3

A) Early phase spinal DSA shows small osseous feeders through the bone to the basivertebral vein (arrowhead) and epidural veins (arrow). B) Late phase spinal DSA shows epidural to intradural reflux through a vein at the right L1 pedicle (arrow) and dilated perimedullary veins (arrowheads). C) Transpedicular needle position (posterior view) and the coaxially inserted Chiba needle (arrow) pointing medially. D) Intravertebral venography (posterior view) shows transpedicular needle (large arrow), the extradural to intradural connection (arrowhead) and the dilated perimedullary veins (small arrow). E) Intravertebral superselective injection through the 22 G coaxially inserted Chiba needle shows details of the intravertebral channel (arrow) and its epidural drainage through the basivertebral vein. F) Post embolization intravertebral venography through the introducer needle showing closure of the intraosseous venous part of the fistula.

Figure 4

Post treatment axial CT shows glue cast in the right part of the intravertebral vascular channel and in the basivertebral vein (arrowhead) and the needle channel through the right pedicle (arrow).

Figure 5

A) Coronal thin slice MIP of the spinal canal in arterial phase showing normal anatomy and no dilatation of intraspinal veins. B) Post embolization sagittal T2-weighted MRI shows normalisation of the previously observed pathological medullary signal and reduction of the previously dilated perimedullary veins.