Rishabh Jain
University of Texas Medical Branch
Introduction: Spinal dural arteriovenous fistulas (SDAVFs) are rare, treatable pathologies encountered in the spinal cord. SDAVFs in the cervical spine are particularly dangerous as they can cause quadriplegia or subarachnoid hemorrhage. However, given the complexity of high cervical SDAVFs, surgical intervention may be difficult to perform. As a result, endovascular approaches should be considered as an option as well, but care should be taken to avoid unintended spinal cord ischemia. Here, we describe the case of a patient who was found to have SDAVF following admission for subarachnoid hemorrhage. Methods: A 40-year-old female presented with a several days history of severe headache, nausea, vomiting, nuchal rigidity, and limited mobility of her bilateral upper extremities. Imaging demonstrated a minor subarachnoid hemorrhage, and a follow-up computed tomography angiogram revealed a SDAVF located at C2-3. The patient was discussed at a multidisciplinary Endovascular Surgical Case Conference. The C2-3 radicular artery proximal to the fistula feeder anastomosed with the anterior spinal artery, increasing the risk of complication should the patient undergo embolization. It was noted that surgical management of the SDAVF would require a suboccipital craniotomy due to its proximity to the foramen magnum. It was decided that initial endovascular embolization would be attempted to reduce the risk of curative surgery. Results: The patient was placed under minimal anesthesia to maintain consciousness. A catheter was threaded up to the radicular artery feeding the SDAVF, and lidocaine was administered. A neurologic exam was then performed to ensure that there were no deficits as a result of the lidocaine provocative testing, indicating that embolization would be safe. The patient was without deficits, and we proceeded with glue embolization. The patient awoke without complications, and subsequent imaging revealed no filling of the medullary vein that previous drained the fistula. Conclusion: Cervical SDAVFs are rare and architecturally complex clinical entities. Treatment can be difficult as a result, and a multidisciplinary approach is often necessary to correct the anatomic abnormality. We reported here the case of a patient with a cervical SDAVF whose risk of embolization was assessed by a lidocaine provocative test. She subsequently underwent successful embolization without further need for neurosurgical intervention.