Positional vomiting due to a thoracic spinal dural arteriovenous fistula

Case report

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✓ The authors report the unique case of a patient with a thoracic spinal dural arteriovenous fistula (DAVF) causing remote brainstem symptoms of positional vomiting and minimal vertigo. Magnetic resonance (MR) imaging of the brain demonstrated high signal abnormality in the medulla, presumably related to venous hypertension, and spinal MR imaging revealed markedly dilated veins along the dorsal aspect of the cord. Spinal angiography confirmed the presence of a thoracic spinal DAVF. Disconnection of the DAVF from the spine resulted in a marked improvement in symptoms and resolution of the preoperative MR imaging—documented abnormalities. The authors highlight the rare syndrome of positional vomiting as a brainstem symptom and conclude that spinal DAVFs should be considered in the differential diagnosis of high signal MR imaging abnormalities localized to the brainstem.

Article Information

Address reprint requests to: Dennis Cordato, F.R.A.C.P., Ph.D., Suite 7E, Level 5, St. George Private Hospital, 1 South Street, Kogarah, New South Wales, 2217, Australia. email: dcordato@southern-neurology.com.au.

© AANS, except where prohibited by US copyright law.

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Figures

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    Transverse fluid-attenuated inversion recovery (left and center) and sagittal T2-weighted (right) MR images of the medulla and spinal cord demonstrating medullary swelling and abnormal signal intensity (arrows) and markedly dilated veins along the dorsal aspect of the spinal cord extending rostrally to the ventral and dorsal surface of the medulla.

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    Selective anteroposterior right T-3 intercostal artery (vertical black arrow) angiogram demonstrating the site of the DAVF (white arrow), its draining vein, and retrograde flow rostrally in the coronal venous plexus (horizontal black arrows) extending into the posterior cranial fossa.

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    Intraoperative photograph (upper) and schematic diagram (lower) showing the dura mater (1), “sucker” head (2), spinal cord and dilated coronal venous plexus (3), arterialized draining vein exiting the dura (4), region of raised visible arterialized veins and arteries within the dura constituting fistula (5), and edge durotomy (6).

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    Transverse fluid-attenuated inversion recovery (left and center) and sagittal T2-weighted (right) MR images of the medulla and spinal cord demonstrating resolution of the medullary high signal abnormality as well as the markedly abnormal veins previously visible along the dorsal aspect of the spinal cord.

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