Spinal Arteriovenous Fistula with Progressive Paraplegia after Spinal Anaesthesia
A 20-year-old female was referred to our hospital, with a history of progressive sensory-motor paraplegia and a spinal magnetic resonance imaging (MRI) demonstrating conus medullaris edema as well as dilated vessels on the cord surface. Her history began two years prior to her admission to our hospital, while she was admitted to another hospital with acute abdomen and the suspicion of a ruptured ectopic pregnancy. For some reason, most likely related to the fact that she had eaten shortly before her admission, spinal anaesthesia was decided instead of general anesthesia. Several unsuccessful attempts for access were made. She described that during those attempts she felt a sharp electric current-like sensation in both the lower extremities followed by pins and needles-like sensation. She complained intensely and further attempts were aborted. Thereafter and during her hospitalisation she was complaining of disturbing sensory symptoms involving her legs. Over the following weeks, she started to have a progressive 'numbness' of her lower limbs followed by slowly progressive spastic paraplegia over the next twenty months. During that period and especially soon after her discharge, she visited her family doctor and described her problem, which was not properly evaluated and further investigation was not followed. She was getting worse in spite of physiotherapy, which was suggested. During the last six months she developed clear spasticity and paraparesis and was investigated by MRI, which revealed conus medullaris edema and dilated vessels on the surface of the spinal cord. A vascular lesion was suspected and the patient was referred to us for further investigation and treatment. On admission the general physical and systemic examination was unremarkable except for the neurological findings. No family history or sign of any genetic disease related to a central nervous system vascular lesion was discovered. Her neurological findings included severe spastic paraplegia-she came on a wheelchair-with hypoesthesia below the twelfth thoracic (T12) dermatome. Tone was markedly increased, and knee reflexes were exaggerated. Both the plantar reflexes were elicited with an up-going great toe and both her legs were affected by some atrophic changes. Bladder and intestinal sphincter function were preserved.\nAfter her admission she underwent a spinal angiogram that revealed a single, direct, moderate flow, single-hole type AVF at the left first lumbar (L1) level supplied by the anterior spinal artery (ASA), which presented a small dilatation just at the shunt site (). The draining vein and the superficial venous network were dilated with slow flow indicating venous congestion (). In the same session and under general anaesthesia we approached the lesion endovascularly using a Magic 1.2 Fr microcatheter (Balt, Montmorency, France) which was advanced over a Mirage 0.008-inch guidewire (ev3, Irvine, CA, USA). A single drop of N-butyl cyanoacrylate glue 50% was delivered just at the shunt site, which resulted to a complete occlusion of the fistula ().\nAfter awakening, she reported some immediate sensory improvement. Six months after the operation she was able to walk again with assistance. No complete motor recovery was achieved after one year despite of intensive rehabilitation.