Lumbar tap–induced subarachnoid hemorrhage in a case of spinal epidural arteriovenous fistula

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The authors report the case of a 70-year-old woman with lumbar spinal epidural arteriovenous fistula (SEDAVF) who experienced subarachnoid hemorrhage (SAH) after a diagnostic lumbar puncture. According to the literature, perimedullary spinal vein enlargement is a hallmark of spinal vascular diseases; however, there are certain cases in which routine sagittal MRI fails to disclose signal flow voids. In such cases, patients may undergo a lumbar tap to investigate the possible causes of spinal inflammatory or demyelinating disease. Recognizing this phenomenon is essential because lumbar puncture of the epidural venous pouch or an enlarged intradural vein in SEDAVF may induce severe SAH. A high clinical index of suspicion can prevent similar cases in lumbar SEDAVF.

ABBREVIATIONS AVF = arteriovenous fistula; SAH = subarachnoid hemorrhage; SEDAVF = spinal epidural AVF.

Article Information

Correspondence Toshiki Endo: Kohnan Hospital, Sendai, Japan. endo@nsg.med.tohoku.ac.jp.

INCLUDE WHEN CITING Published online August 10, 2018; DOI: 10.3171/2018.3.SPINE171343.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Thoracic (A) and lumbar (B and C) sagittal T2-weighted MR images obtained before the diagnostic lumbar puncture. Note: Panels B and C are the same images. A and B: Hyperintense areas are seen, extending in the spinal cord from T8 (A) to the conus medullaris (B) (arrowheads in A and B). C: Serpiginous flow voids at L2 and L3 are marked with a dashed line. Before the patient was referred to us, the flow void did not draw clinical attention. Therefore, a diagnostic lumbar puncture was performed after MRI.

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    Thoracolumbar sagittal MR images obtained after the lumbar puncture. A: T1-weighted image showing high-intensity areas, indicating the source of the subarachnoid hemorrhage (arrow). B: T2-weighted image showing hyperintense areas in the spinal cord (arrowheads) that are more apparent at thoracolumbar levels than they had been before the lumbar puncture.

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    Selective spinal angiograms of the left L3 segmental artery (A and B) and axial CT image with contrast (C). A: Anteroposterior view showing the radicular artery as a feeder (large arrow). The epidural venous pouch (arrowhead) and ascending perimedullary vein (small arrows) are seen. B: Three-dimensional reconstructed image showing the angioarchitecture of the lesion. The arrows and arrowhead indicate the same structures as in panel A. C: At the L3 level, ventral to the dural sac, the epidural pouch is seen (arrowhead). In all images, the left side (L) is shown.

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    Intraoperative photograph showing an enlarged draining vein (large arrow), originating from the root sleeve of the left L3. The small arrows indicate the L3 nerve root. After dissection, a remnant of the hematoma (arrowheads) is seen rostral to the vein. This was where the bleeding occurred after the lumbar puncture. Nonetheless, an exact mechanism leading to the SAH remained undetermined. Figure is available in color online only.

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    Thoracolumbar sagittal T2-weighted MR image obtained at 12 months after surgery, confirming the disappearance of flow voids and abnormal intramedullary hyperintense areas.

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