Acute Clinical Worsening after Steroid Administration in Cervical Myelitis May Reveal a Subdural Arteriovenous Fistula

Congestive myelopathy due to spinal dural arteriovenous fistula mimicking CNS demyelinating disease

Spinal dural arteriovenous fistula (SDAVF) is known for its ambiguous and various clinical presentations. Among these presentations, congestive myelopathy is one of the most common, yet it is challenging to correctly diagnose SDAVF at initial presentation. Several diseases present as myelopathy, including demyelinating diseases. Herein, we present two cases of congestive myelopathy due to SDAVF presenting to the emergency room (ER) with progressive quadriparesis. Even though the patients had a proper magnetic resonance imaging (MRI) examination from the initial presentation, there was a delay in making a final diagnosis. Both patients' clinical presentation and MRI mimicked central nervous system (CNS) demyelinating disease initially, and a more thorough examination revealed SDAVF. Such a delay in diagnosis can result in more neurological deterioration and may result in more sequelae. Hence, SDAVF should always be considered as a differential diagnosis when examining patients with myelopathy.

Unmasking of a spinal dural AV fistula on MRI following steroid administration

Background

Spinal dural arteriovenous fistulas (dAVF) remain a rare, diagnostically challenging and possibly correctable condition with important prognostic outcomes dependent primarily on early detection and treatment.

Case presentation

We present a case of a 73-year-old male with progressively worsening neurological symptoms after steroid administration for a presumed diagnosis of transverse myelitis. This case is extremely unique, as the administration of steroids helped unmask an underlying spinal dural arteriovenous fistula by revealing characteristic imaging findings of a dAVF, not seen on the original MRI study.

Conclusion

In the setting of an unclear cause of transverse myelitis and worsening symptoms following steroid administration, the possibility of a ‘masked’ dural AVF should be considered and repeat imaging performed, which might help in the eventual diagnosis and definitive treatment of this elusive entity.

Paralysis After Lumbar Interlaminar Epidural Steroid Injection in the Absence of Hematoma: A Case of Congestive Myelopathy Due to Spinal Dural Arteriovenous Fistula and a Review of the Literature

Paraplegia after interlaminar epidural steroid injection is a rare event and has typically been described after epidural hematoma or direct spinal cord injury. We present a case of an 87-yr-old man who experienced transient lower limb weakness after a lumbar interlaminar epidural steroid injection due to an alternative cause, congestive myelopathy related to an underlying vascular malformation, namely, a spinal dural arteriovenous fistula. This is a poorly recognized and potentially treatable cause of progressive myelopathy. We present this case and review the literature on paraplegia after epidural steroid injection due to spinal dural arteriovenous fistula. Notably, this case of paralysis occurred in association with the lowest volume of epidural injectate reported in the literature to date (4 ml); importantly, this volume is consistent with the current clinical practice guideline standards for the safe performance of interlaminar epidural steroid injections. Physicians should be aware of this potential complication of epidural steroid injection and remain vigilant for the possibility after a procedure, even when performed according to current practice standards.

A practical approach to the diagnosis of spinal cord lesions

Every neurologist will be familiar with the patient with atypical spinal cord disease and the challenges of taking the diagnosis forward. This is predominantly because of the limited range of possible clinical and investigation findings making most individual features non-specific. The difficulty in obtaining a tissue diagnosis further contributes and patients are often treated empirically based on local prevalence and potential for reversibility. This article focuses on improving the diagnosis of adult non-traumatic, non-compressive spinal cord disorders. It is structured to start with the clinical presentation in order to be of practical use to the clinician. We aim, by combining the onset phenotype with the subsequent course, along with imaging and laboratory features, to improve the diagnostic process.

Acute Tetraparesis with Respiratory Failure after Steroid Administration in a Patient with a Dural Arteriovenous Fistula at the Craniocervical Junction

A 63-year-old man developed vomiting, paraparesis, dysuria, bulbar palsy, and orthostatic hypotension over a period of 5 months. Neuroradiological examinations showed a swollen lower brainstem with a dural arteriovenous fistula at the craniocervical junction (DAVF-CCJ). A steroid was administered intravenously in the hospital to relieve brainstem edema. A few hours later, however, the patient developed acute tetraparesis with respiratory failure. Recently, there have been several reports describing the acute worsening of paraparesis in patients with a spinal dural arteriovenous fistula after steroid treatment. In addition to these reports, the present case suggests the risk of administering steroids to patients with DAVF-CCJ, especially those with brainstem dysfunction.

Spinal Cord Infarcts: Risk Factors, Management, and Prognosis

OPINION STATEMENT

There are no standard guidelines for treatment of spinal cord ischemia due to how rare it is and the diverse etiology and presentations involved. In addition, to date, there have been no large clinical trials examining ideal pharmacologic treatment options for spinal cord infarct. In our practice, we rely on hemodynamic augmentation initiated as soon as possible. Otherwise, treatment is usually geared towards the etiology of spinal cord ischemia. For instance, spinal cord ischemia occurring after aortic aneurysmal repair may improve with CSF drainage through a lumbar catheter in the periprocedural setting. Vertebral artery dissection should be treated with antithrombotics. If no clear etiology is found and there is evidence of atherosclerosis in other vascular beds, then management is focused on risk factor modification with blood pressure and glucose control, statins, and antithrombotics.