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. 2022 Spring;22(1):10-14.
doi: 10.31486/toj.21.0110.

Spinal Dural Arteriovenous Fistula: The Missing-Piece Sign

Michael Kelley  1 , Daniel April  1 , Bridget Bagert  2   3 , James Milburn  1 , Andrew Steven  1
Affiliations

Spinal Dural Arteriovenous Fistula: The Missing-Piece Sign

Michael Kelley et al. Ochsner J. 2022 Spring.
No abstract available

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Figures

Figure 1.
Figure 1.
Magnetic resonance imaging of the thoracic spine. (A) Sagittal T2-weighted image through the level of the mid-thoracic spinal cord demonstrates long segment central cord hyperintensity and expansion in the lower thoracic cord (arrowhead) and prominent serpentine T2 flow voids in the posterior intradural space (arrows). Sagittal T1-weighted images (B) before and (C) after contrast administration with fat saturation demonstrate corresponding patchy central cord enhancement (arrowheads) with a discrete nonenhancing segment known as the missing-piece sign (arrow).
Figure 2.
Figure 2.
Axial T2-weighted image through the level of the mid-thoracic spinal cord demonstrates long segment central cord hyperintensity and expansion in the lower thoracic cord (arrowhead).
Figure 3.
Figure 3.
Direct spinal angiography images of the mid-thoracic spine. (A) The artery of Adamkiewicz (arrowhead) arises from the left T6 segmental artery supplying a normal anterior spinal artery (arrow). (B and C) Selective left T8 segmental injection demonstrates an arteriovenous fistula supplied by small branches of the left radicular artery (arrowhead). This arteriovenous fistula drained into the spinal canal via numerous dilated perimedullary veins extending both cranially and caudally (arrows). (D) A Scepter balloon microcatheter (MicroVention Inc) was advanced into the left T8 segmental artery and inflated for protection from reflux. Then 0.6 cc of Onyx-18 (Medtronic) was injected, opacifying the feeding vessels and fistula. After embolization, the Onyx cast is shown with filling of the arterial supply to the fistula (arrow). No supply was visualized from the T7, T8, and T9 segmental arteries after embolization, suggesting complete occlusion.
Figure 4.
Figure 4.
Magnetic resonance imaging of the thoracic spine 14 months postembolization. (A) Sagittal T2-weighted image demonstrates persistent but considerably decreased patchy central cord T2 hyperintensity extending from the T8 level to the conus (arrowhead) with decreased prominence of the venous flow voids in the posterior intradural space (arrow). Sagittal T1-weighted images (B) before and (C) after contrast administration demonstrate mild persistent faint enhancement, considerably improved since the initial examination (arrows).
Figure 5.
Figure 5.
Axial T2-weighted image at the T12 level 14 months postembolization shows mild persistent hyperintense signal with resolved expansion of the central cord (arrow).
See this image and copyright information in PMC

References

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