Spinal Dural Arterial Venous Fistula During Pregnancy
Joann Lohr, Emily Wright, Angie Fellner.
Trihealth, Cincinnati, OH, USA.
OBJECTIVE: An unusual case of progressive of edema and neurologic during pregnancy will be described: an atypical presentation of spinal dural arteriovenous fistula during pregnancy resulting in positional neurologic symptoms.
METHODS: Case report and retrospective review of literature of spinal dural arterial venous fistulas.
RESULTS: A 33 year old G2P1 gestational diabetic presented with severe bilateral pitting edema in her thighs. She also complained of thigh hyperesthesia and had increasing pain. The patient became increasingly symptomatic between presentation at 22 weeks and delivery at 34 weeks gestation. She had three negative duplex vein scans during this period. By the time of delivery her edema extended from scapula to knees, with pain and numbness progressively increasing in severity with upright positioning.
A hypercoagulation profile was non-specific. The patient was heparinized and a retrievable suprarenal IVC filter was placed. Her symptoms became increasingly consistent with spinal dural arteriovenous fistula with symptoms exacerbated by compression of the IVC during pregnancy. She had an uncomplicated delivery by C-section after which her symptoms resolved and IVC filter was removed.
CONCLUSIONS: While spinal dural arteriovenous fistulas very rarely present in younger females (the most common cohort being elderly males), they can have extreme consequences including para or tetraplegia when not properly managed. One must consider the anatomical intricacies with a combination of small low-flow arteriovenous shunts under high venous pressure, a valveless spinal venous system, and compression of the IVC which further obstructs venous flow. The result is edema and a spinal tissue hypoxia which can result in irreversible necrotizing myelopathy of the spinal cord. These consequences may be reversible in the setting of exacerbation during pregnancy. SDAVF must be considered in the setting of progressive gait/sphincter/bladder disturbances accompanied by mono or poly radiculopathy in any patient demographic.
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