Recurrence of perimedullary arteriovenous fistulas after embolization with N-butylcyanoacrylate: Case report

Abstract

The authors report a case of a 37-year-old man with recurrent of perimedullary arteriovenous fistulas (PMAVFs) located at the level of the conus medullais after embolization with N-butylcyanoacrylate (NBCA). The patient was treated 5 years ago in another hospital for two AVFs at separate sites including PMAVFs at the conus medullaris and a dural AVF at the sacral region by transcatheter embolization with NBCA. Complete obliteration of the PMAVFs at the conus medullaris was confirmed by angiography. The dural AVF at the sacral region was treated successfully thereafter by surgery because of recanalization. However, he was admitted to our institution with a recurrence of low back pain and thoracic tightness. Neurological examination showed a spastic paraparesis, disturbance of superficial sensation below the L4 dermatome on both sides and dysuria. Magnetic resonance images revealed an enlarged conus medullaris and many serpentine flow-void signals from the lower thoracic to the upper lumbar region. Recurrence of the AVFs at the conus medullaris was comfirmed by selective angiography. He was treated surgically with the assistance of intraoperative microvascular Doppler and spinal digital subtraction angiography (DSA). He made a good postoperative recovery with gradual improvement of his neurological symptoms. Both surgical and endovascular methods have a role in the management of PMAVFs. However, after a failed or partial embolization of a PMAVF, surgery should be considered so as to achieve complete obliteration. Intraoperative microvascular Doppler and spinal DSA are of valuable assistance in surgical closure of spinal AVFs. Close follow-up observation is also required even if complete obliteration is confirmed by angiography.