Fig 2.

A 68-year-old man with a 3-month history of saddle anesthesia, constipation, difficulty voiding, and numbness in the lower extremities. T2-weighted images of the lumbar and thoracic spine demonstrate high T2 signal in the lower thoracic cord and conus (A and B). Due to clinical suspicion of SDAVF, an angiogram was obtained before referral to our center. C, The angiogram clearly demonstrates the fistula arising from the L2 radiculomeningeal artery; however, it was interpreted as a negative finding. Before the diagnosis was made, the patient underwent an extensive imaging and clinical evaluation, including a panel negative for paraneoplastic syndrome, PET/CT, and lumbar puncture. Two rounds of IV Solu-Medrol therapy resulted in worsening of symptoms. The patient also underwent a T10–T11 laminectomy and 2 spinal cord biopsies. D, Repeat spinal angiography re-demonstrates the fistula.