Teaching NeuroImages: Lower cervical spine dural arteriovenous fistula presenting as subarachnoid hemorrhage

Abstract

A 39-year-old man presented with sudden neck pain and headache. CT showed subarachnoid hemorrhage around medulla oblongata. Diagnostic angiography demonstrated a rare spinal dural arteriovenous fistula at the level of C5. The fistula recruits additional spinal pial arteries from the anterior spinal artery as feeding artery, most likely due to the venous sump effect induced by the dural shunt.1 A spinal pial aneurysm, potential cause of hemorrhage, was presumed to be related to the hemodynamic stress produced by the high flow through the shunt (figure 1).2 Endovascular embolization of the aneurysm and surgical interruption of the fistula was performed successfully (figure 2).