Bridging the gap between neuroimaging and neurosurgery: a case of epidural arteriovenous fistula with an intradural presentation. Illustrative case

Abstract

Background: Epidural arteriovenous fistulas (eAVFs) are rare vascular malformations often mistaken for their intradural counterparts due to similar angiographic features. Differentiation between epidural and intradural vascular lesions is crucial as it impacts surgical planning and prognosis. Despite advancements in diagnostic imaging, these entities can be misinterpreted and challenge management.

Observations: The authors report the case of a 68-year-old male suspected to have a type I dural arteriovenous fistula based on magnetic resonance angiography and angiographic evaluation. He presented with progressive myelopathy and multiple neurological symptoms exacerbated by recent trauma. A superselective angiogram of the right T10 segmental artery suggested an intradural arteriovenous fistula; however, intraoperatively, the lesion was epidural. The arterialized venous structures were obliterated, and the patient reported significant postoperative symptomatic improvement.

Lessons: This case highlights the critical importance of comprehensive imaging and cautious interpretation in the diagnosis of spinal vascular malformations. It also underscores the need for a multidisciplinary approach to ensure accurate diagnosis and effective treatment. Surgeons must be prepared for intraoperative findings that diverge from preoperative imaging to adapt surgical strategies accordingly. Furthermore, this case contributes to the evolving understanding of eAVFs, suggesting that revised imaging protocols may be required to better distinguish epidural from intradural vascular abnormalities. https://thejns.org/doi/10.3171/CASE24331.

Keywords: dural arteriovenous fistula; epidural arteriovenous fistula; neuroimaging.

FIG. 1.

Sagittal T2-weighted MRI demonstrating signal change and midthoracic cord edema.

FIG. 2.

Sagittal MRA showing the SDAVF, providing clear visualization of the abnormal vascular connection.

FIG. 3.

Sequential frames (A–F) from a three-dimensional rotational angiogram of the right T11 segmental artery revealing early venous shunting, presumed to be a type I SDAVF.

FIG. 4.

Intraoperative photograph showing the epidural location of the AVF, with the fistulous connection and surrounding vascular structures clearly visible outside the dura mater.