Spinal dural arteriovenous fistula presenting with lower extremity weakness and intracranial hemorrhage: A case report

Spinal dural arteriovenous fistulas (AVFs) are uncommon vascular malformations that typically present with progressive myelopathy and are rarely associated with intracranial hemorrhage. We describe a 76-year-old male who initially had a normal noncontrast head CT, followed by rapid development of a large right cortical intraparenchymal hemorrhage with bilateral subarachnoid hemorrhage (SAH) on repeat CT performed three hours later. Subsequent spine MRI demonstrated extensive dilated perimedullary vessels and diffuse thoracic spinal cord T2 hyperintensity, raising concern for a spinal vascular malformation. Spinal angiography confirmed a spinal dural AVF arising from the right L2 segmental artery with early venous drainage into a congested spinal venous network, which was successfully treated with trans arterial embolization. This case uniquely captured the dynamic radiologic evolution of intracranial hemorrhage temporally associated with a spinal dural AVF and highlights the importance of considering spinal vascular etiologies when intracranial imaging findings do not explain the clinical presentation.