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Images in Neurology |

Dural Arteriovenous Fistula at the Craniocervical Junction Mimicking Acute Brainstem and Spinal Cord Infarction

Elliott Salamon, DO; Athos Patsalides, MD; Y. Pierre Gobin, MD; Alejandro Santillan, MD; Matthew E. Fink, MD
JAMA Neurol. 2013;70(6):796. doi:10.1001/jamaneurol.2013.1946.
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A 43-year-old right-handed man was admitted to our hospital after he developed an abrupt onset of persistent vomiting and intermittent hiccups that progressed to difficulty swallowing, double vision, inability to walk, and difficulty initiating urination. Findings from the neurologic examination were notable for guttural dysarthria, left hypertropia, and right-beating nystagmus on right horizontal gaze. A right upper motor flattened nasolabial fold and decreased palatal elevation on the left side were present. His tongue protruded to the right. His motor examination revealed the presence of a left arm pronator drift and silent Babinski responses. The patient exhibited a severe truncal ataxia and urinary retention.

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Figure 1. Magnetic resonance imaging at presentation. Sagittal T2-weighted magnetic resonance image showing increased signal intensity at the level of the medulla (arrow) and spinal cord and flow voids (arrowheads) ventral to the brainstem.

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Figure 2. Catheter angiography before the embolization. Right vertebral artery angiogram showing a dural arteriovenous fistula with arterial supply via a branch arising from the V4 segment of the right vertebral artery (arrow) and the venous drainage along the medulla and spinal cord (arrowheads).

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Figure 3. Magnetic resonance imaging 3 months after treatment. Postembolization sagittal T2-weighted magnetic resonance image showing resolution of the flow voids and signal hyperintensity.

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