Delayed Diagnosis of Spinal Dural Arteriovenous Fistula: A Case Report and Scoping Review

Abstract

Spinal dural arteriovenous fistula (SDAVF) is among the most common arterial shunt diseases typically found in middle aged or older men. Herein, we aimed to clarify the reasons for misdiagnoses and delayed diagnoses of SDAVF, determine how these affect prognoses, and establish how they can be prevented. We conducted a PubMed/MEDLINE literature search using "spinal dural arteriovenous fistula", "delayed diagnosis", "late diagnosis", and "misdiagnosis" terms. We identified 18 articles, including 965 SDAVF cases. Patients were predominantly males (71.8-100.0%) (mean age: 53.5-71.0 years). Misdiagnoses rates varied (17.5-100.0%) and encompassed many conditions. The mean time between early manifestations and confirmed diagnosis was approximately 10-15 months and from the first radiologic image revealing dural arteriovenous fistula (DAVF) features to diagnosis was 9.2-20.7 months. Posttreatment outcomes showed a significant improvement in motor functions, gait, and micturition, particularly in patients exhibiting preoperative symptoms over a short period. SDAVF is frequently misdiagnosed or subject to delayed diagnosis, causing poor clinical outcomes. SDAVF symptoms including progressive lower-limb weakness, paresthesia, and vesicorectal dysfunction are indications for spinal magnetic resonance imaging with subsequent spinal angiography, wherein DAVF is evidenced by extensive T2 hyperintensity and flow-void abnormalities. We reported a representative case with delayed diagnosis.

Keywords: clinical presentation; differential diagnosis neuroimaging findings; misdiagnosis; myelitis; spinal arteriovenous fistula; spinal arteriovenous malformation; spinal vascular disease.

Figure 1

Identification of thoracic spinal dural arteriovenous fistula studies from database and register.

Figure 2

Computerized tomography (CT) and magnetic resonance (MR) images from a patient with dural arteriovenous fistula (DAVF); (A) CT scan of the head showing left chronic subdural hematoma; (B) sagittal T2-weighted MR image of cervicothoracic spine showing cervical canal stenosis, spinal cord edema, and flow voids around the cord; (C) sagittal T2-weighted MR image of thoracolumbar spine, highlighting spinal cord edema and flow voids around the cord; (D) sagittal contrast-enhanced MR image displaying enhancement of spinal cord condition (arrow).

Figure 3

Pre- and post-treatment magnetic resonance (MR) images from a patient with dural arteriovenous fistula (DAVF); (A) pretreatment sagittal T2-weighted MR image of the thoracolumbar spine showing spinal cord edema and flow voids around the cord; (B) posttreatment sagittal T2-weighted MR image of the thoracolumbar spine showing edema reduction and flow-void disappearance.

Figure 4

Three-dimensional digital subtraction angiographic (DSA) images and spinal X-ray of a patient with dural arteriovenous fistula (DAVF). (A) Anteroposterior DSA view of the right Th-9 and -10 segmental arteries; DAVF, intradural arterialized vein, and dilated perimedullary veins can be seen; (B) anteroposterior DSA view of right Th-9 segmental artery displaying a shunt lesion from selective catheterization of right Th-9 radicular branch and a tangle of arterialized veins in the central spinal canal; fistula can be seen at right Th-9 nerve sleeve; (C) post-treatment X-ray showing the presence of N-butyl cyanoacrylate (NBCA); (D) post-treatment anteroposterior DSA view of right Th-9 and -10 segmental arteries showing disappearance of the spinal DAVF.

Figure 5

Diagnostic process for spinal dural arteriovenous fistula detection. SDAVF represents spinal dural arteriovenous fistula; MRI, magnetic resonance imaging; 3DCT, three-dimensional computed tomography; DSA, digital subtraction angiography.