Engorged and tortuous intradural filum terminale vein as a sign of a sacral dural arteriovenous malformation

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Abstract

Sacral spinal dural arteriovenous (AV) malformation is rare and its clinical features are not specific to differentiate sacral dural AV malformation from the superiorly located ones. A sacral dural AV malformation, therefore, is usually diagnosed after negative thoracic and lumbar arteriograms. In this report, we propose a myelographic or magnetic resonance (MR) sign of engorged and tortuous intradural filum terminale vein as an indication of a sacral dural AV malformation. When this sign is seen, pelvic arteriography should be performed first.

Introduction

Spinal dural arteriovenous (AV) malformation was first described by Kendall and Logue in 1977 [1] when they reported a series of ten patients with spinal vascular malformations in whom the nidus was located in the dura or extradura and drained by the intrathecal veins. In spite of the advent of magnetic resonance imaging (MRI), spinal angiography remains the diagnostically decisive neuroimaging procedure in patients with spinal dural AV malformations. However, one of the most challenging aspects of performing spinal angiography is localizing the level(s) of the fistulous tract(s). Lumbar and thoracic spinal angiographies are usually performed first because 80% of the nidi are around these sites [2]. If the nidus is not found after studying all of the thoracic and lumbar radicular arteries, a delayed film with injection of the artery of Adamkiewicz will be usually obtained [2]. If the delayed films indicate the presence of venous hypertension, pelvic, cervical, or even the intracranial studies will be performed to exclude other location dural AV malformation. The whole process of selective catheterization can be lengthy and tedious. In this report, we showed a case of sacral dural AV malformation with an engorged and tortuous intradural filum terminale vein shown on preangiographic myelography and MR imaging. The anatomy of filum terminale vein is reviewed and its relationship with the sacral dural AV malformation is discussed.

Section snippets

Case report

A 67-year-old male suffered from progressive bilateral feet and legs numbness for 2 years. Recent 4 months, he experienced aggravated numbness, soreness and muscle cramps of the legs especially after walking for a long distance. Reviewing his medial history, no major systemic disease was told.

Neurological examination demonstrated a left leg muscle power decrease (grade 4) and absence of left knee and ankle jerks. Muscle wasting at the left gastrocnemius and the extensor digitorum longus was

Discussion

Sacral spinal dural AV malformation is rare. A review of literature reveals only 15 such cases [2], [3], [4], [5]. Among them, the age of onset, sex predominance and clinical features are not essentially different from those encountered with more superiorly located nidi [2], [3], [4]. They also frequently occur on middle-age male with symptoms of progressive myelopathy or cauda equina syndrome [3]. Therefore, the clinical features are not sufficient to differentiate sacral dural AV malformation

Acknowledgements

This study was partly supported by grant NSC 89-2320-B-182A-028 (to C.J. Chen) from the National Science Council, Taiwan.

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