Acute paraplegia in patient with spinal dural arteriovenous fistula after lumbar puncture and steroid administration: A case report

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Spinal dural arteriovenous fistula is an uncommon cause of longitudinal transverse myelitis.

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Spinal dural arteriovenous fistula can be easily misdiagnosed.

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It usually presents with venous congestive myelopathy symptoms and misdiagnosis is common.

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Prescence of flow voids on MRI should raise the suspicion of underlying fistula.

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Intravenous steroid and lumbar puncture may be associated with acute neurological deterioration.

Introduction and importance

Spinal dural arteriovenous fistula (SDAVF) is an uncommon cause of longitudinal extensive transverse myelitis (LETM). It usually presents with vague congestive myelopathy symptoms and diagnosis is usually difficult on initial presentation. Common daily neurological interventions can aggravate the underlying pathophysiology leading to undesirable acute neurological deterioration. Intravenous steroids administration and lumbar (LP) puncture as a diagnostic tool are amongst the most commonly reported aggravating interventions. This rare case presentation highlights this association with its negative impact on the patient outcome in misdiagnosed cases.

Case presentation

The authors present a sixty-eight-year-old male with paraplegia following steroid administration and LP for presumed inflammatory/autoimmune LETM in the setting of misdiagnosed SDAVF. The absence of flow voids on the conventional T2-weighted magnetic resonance image (MRI) lead to misdiagnosis. He had satisfactory neurological recovery few hours after surgical disconnection.

Clinical discussion

SDAVF is known to cause congestive myelopathy symptoms. Spinal angiogram is the gold standard for diagnosis. Although the exact mechanism is not fully understood, misdiagnosed cases like our case can develop severe neurological deterioration with steroid administration and lumbar puncture.

Conclusion

Although SDAVF is an uncommon cause of LETM, Clinicians should carefully exclude it before proceeding to steroid administration or performing LP as they can lead to devastating neurological deterioration.

Primary intradural Hodgkin lymphoma of the conus medullaris and cauda equina: case report

Primary Hodgkin lymphoma of the central nervous system is an exceedingly rare condition with very few cases reported in the literature. Isolated intradural involvement of the spine is rarer still, with only two prior cases located in the extramedullary cervical and lumbosacral spine. We present a 48-year-old female who was presented with back pain, radiculopathy and a short history of sphincter disturbance and was subsequently found to have a lobulated homogenously enhancing exophytic lesion involving the conus medullaris and cauda equina on magnetic resonance imaging. Histopathological examination demonstrated the features of classic Hodgkin lymphoma. In this report, we present a case of primary intramedullary Hodgkin lymphoma involving the conus medullaris and cauda equina.