Onyx embolization of a thoracolumbar perimedullary spinal arteriovenous fistula in an infant presenting with subarachnoid and intraventricular hemorrhage

Case report

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Identifying a source of spontaneous subarachnoid hemorrhage (SAH) or intraventricular hemorrhage (IVH) in patients with negative results on cranial angiographic imaging can be a diagnostic challenge. The authors present the case of a 14-month-old girl who presented with lethargy and spontaneous SAH and IVH, and later became acutely paraplegic. Except for the SAH and IVH, findings on neuroimages of the brain were normal. Magnetic resonance imaging revealed an intramedullary thoracolumbar spinal cord hemorrhage that was found to be associated with arterialized veins intraoperatively. Catheter-based diagnostic angiography identified a spinal perimedullary macroarteriovenous fistula (macro-AVF) that was completely embolized with Onyx, negating the need for further surgical intervention. The authors believe this to be the first reported case of a thoracolumbar perimedullary macro-AVF presenting with SAH and IVH. In addition, descriptions of Onyx embolization of a spinal AVF in the literature are rare, especially in pediatric patients.

Abbreviations used in this paper: AVM = arteriovenous malformation; ICH = intracranial hemorrhage; IVH = intraventricular hemorrhage; macro-AVF = macroarteriovenous fistula; NBCA = N-butyl-2-cyanoacrylate; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Tyler J. Kenning, M.D., Division of Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, MC 10, Albany, New York 12208. email: kennint@mail.amc.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Admission cranial CT scans obtained without contrast. A: A hemorrhage within the fourth ventricle and an SAH within the basal cisterns are revealed. B: An SAH within the basal cisterns is revealed. C: A hemorrhage within the third ventricle is demonstrated. D: A hemorrhage within the lateral ventricles is seen.

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    Spinal MR images obtained after onset of acute paraplegia. A: Sagittal T2-weighted MR image showing T11–12 intramedullary acute hemorrhage with edema extending cranially and a significantly distended bladder. B: Axial T2-weighted MR image with hemorrhage filling a large portion of the spinal cord's transverse diameter and multiple vascular flow voids anterior and to the left of the cord. C: Axial T2-weighted MR image of the spine just caudal to the area of hemorrhage, showing large vascular flow voids to the left of the spinal cord.

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    Catheter angiography studies showing an AVF fed by the lumbosacral artery and draining into a venous varix at the level of L-1. Left: Preembolization study. Right: After embolization with Onyx-18.

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