Vasdev A, Lefournier V, Bessou P, Dematteis M, Crouzet G
Service de Neuro-Radiologie, CHU de Grenoble.
J Neuroradiol. 1994 Apr;21(2):134-54.
The authors report 2 new cases of intracranial dural fistula draining into spinal veins. Comparisons with 19 other published cases showed that dural fistulae of the spine share common features with intracranial fistulae. The first case concerned a 78-year old woman presenting with a thoraco-lumbar myelopathy which proceeded by increasingly severe bouts and ended within 6 months in a flaccid sensorimotor paraplegia with urinary incontinence. Paraclinical examinations consisted of MRI, myelography and spinal as well as cerebral arteriography. MRI and thoraco-lumbar myelography displayed marks of dilated retrospinal vessels. Spinal arteriography showed no arteriovenous malformation, but the venous return of Adamkiewicz artery was not visible. Diagnosis was made by cerebral arteriography which demonstrated an intracranial arteriovenous fistula in the occipital region, draining into the posterior spinal vein. Treatment was endovascular and consisted of embolization by micro-coils, but clinical improvement was mediocre. Six months later, as the clinical picture was getting worse a second arteriography was performed. It showed recanalization of the fistula which was embolized again, using both coils and particles. No improvement in spinal cord deficit was observed. The second case was that of a 42-year old man presenting with paraparesis, tetrapyramidal syndrome, sensory deficit at T9, peribuccal dysaesthesias and genito-urinary sphincteral disorders, all gradually getting worse. The paraclinical exploration was the same as in the first case. MRI and myelography showed retrospinal vascular impressions. Spinal arteriography was normal, except for the lack of venous return of Adamkiewicz artery. Cerebral arteriography detected an intracranial dural arteriovenous fistula in the occipital region, draining into the anterior and posterior spinal veins. Treatment was surgical, consisting of exclusion of the arteriovenous fistula. Partial clinical improvement was noted. These two cases, compared with those of the literature, shared a number of features with spinal dural arteriovenous fistulae: they occur in middle-aged and predominantly male patients, and the clinical signs of ascending myelopathy are caused by the same physiopathological mechanism of spinal vein hyperpressure. Lesions of the medulla oblongata or the cervical spinal cord are found only in intracranial arteriovenous fistulae draining into spinal veins. Diagnosis is based on data provided by myelography (impressions of dilated and sinous vessels) and MRI (low-intensity perispinal signals, widening of the conus medullaris with high-intensity centrospinal signal); spinal cord angiography only shows a lack of venous return of Adamkiewicz artery without any other abnormality, whereas cerebral arteriography confirmed the diagnosis of intracranial dural arteriovenous fistula draining into spinal veins.
作者报告了2例颅内硬脑膜瘘引流至脊髓静脉的新病例。与其他19例已发表病例的比较显示，脊柱硬脑膜瘘与颅内瘘有共同特征。第一例是一名78岁女性，表现为胸段-腰段脊髓病，病情呈逐渐加重的发作，6个月内发展为弛缓性感觉运动性截瘫并伴有尿失禁。辅助检查包括MRI、脊髓造影以及脊髓和脑血管造影。MRI和胸段-腰段脊髓造影显示脊髓后血管扩张的迹象。脊髓血管造影未显示动静脉畸形，但Adamkiewicz动脉的静脉回流不可见。通过脑血管造影确诊，显示枕部有一颅内动静脉瘘，引流至脊髓后静脉。治疗采用血管内介入，通过微线圈进行栓塞，但临床改善一般。6个月后，由于临床症状恶化，再次进行血管造影。显示瘘管再通，再次使用线圈和微粒进行栓塞。脊髓功能缺损未见改善。第二例是一名42岁男性，表现为双下肢轻瘫、锥体束征、T9水平感觉障碍、颊周感觉异常和泌尿生殖括约肌功能障碍，所有症状均逐渐加重。辅助检查与第一例相同。MRI和脊髓造影显示脊髓后血管压迹。脊髓血管造影正常，除了Adamkiewicz动脉缺乏静脉回流。脑血管造影检测到枕部有一颅内硬脑膜动静脉瘘，引流至脊髓前静脉和后静脉。治疗采用手术，即排除动静脉瘘。临床症状有部分改善。与文献中的病例相比，这两例与脊柱硬脑膜动静脉瘘有许多共同特征：它们发生在中年患者，以男性为主，上升性脊髓病的临床体征由脊髓静脉高压的相同病理生理机制引起。延髓或颈段脊髓病变仅在引流至脊髓静脉的颅内动静脉瘘中发现。诊断基于脊髓造影（扩张和迂曲血管的压迹）和MRI（脊髓周围低信号、脊髓圆锥增宽伴脊髓中央高信号）提供的数据；脊髓血管造影仅显示Adamkiewicz动脉缺乏静脉回流，无任何其他异常，而脑血管造影证实了引流至脊髓静脉的颅内硬脑膜动静脉瘘的诊断。
