title: Cervical spine dural arteriovenous fistula with coexisting spinal radiculopial artery aneurysm presenting as subarachnoid hemorrhage: case report.
abstract: BACKGROUND
  We present a patient with a cervical spine dural arteriovenous fistula associated with a radiculopial artery aneurysm at the same vertebral level presenting with subarachnoid hemorrhage.
  
  
  METHODS
  A 45-year-old Native American man presented with sudden-onset severe headache, lethargy, and right hemiparesis. Computed tomography (CT) of the head showed subarachnoid hemorrhage and hydrocephalus. A subsequent CT of the neck showed an anterior spinal subdural hematoma from C2 to C4 causing mild cord compression. Carotid and vertebral angiography failed to demonstrate an intracranial aneurysm, but showed a spinal dural arteriovenous fistula originating from the right vertebral artery at the C5 neuroforamen. The severity of the patient's symptoms, atypical for rupture of a dural arteriovenous fistula, prompted more thorough angiographic evaluation. Thus, injection of the right thyrocervical trunk was performed, demonstrating a 4-mm spinal radiculopial artery aneurysm. Following ventriculostomy, a hemilaminectomy from C4 to C7 was performed with disconnection of the fistula from its drainage system. Subsequent resection of the aneurysm, which was determined to be the cause of the hemorrhage, was accomplished. The patient improved neurologically and was discharged to rehabilitation.
  
  
  CONCLUSIONS
  Spinal cord aneurysms from a separate vascular distribution may coexist with spinal dural arteriovenous fistulas. In the setting of spinal hemorrhage, especially in situations with an atypical clinical presentation, comprehensive imaging is indicated to rule out such lesions.
authors.affiliation: Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. joshualu@usc.edu
authors.forename: Joshua W
authors.initials: JW
authors.lastname: Lucas
authors.forename: Jesse
authors.initials: J
authors.lastname: Jones
authors.forename: Azadeh
authors.initials: A
authors.lastname: Farin
authors.forename: Paul
authors.initials: P
authors.lastname: Kim
authors.forename: Steven L
authors.initials: SL
authors.lastname: Giannotta
mesh_terms: D000783:Aneurysm / Q000150:complications* / Q000473:pathology / Q000532:radiotherapy; D000792:Angiography; D020785:Central Nervous System Vascular Malformations / Q000150:complications* / Q000601:surgery; D002574:Cervical Vertebrae / Q000601:surgery; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D013345:Subarachnoid Hemorrhage / Q000503:physiopathology* / Q000601:surgery; D014057:Tomography, X-Ray Computed; D014696:Ventriculostomy / Q000379:methods; D014711:Vertebral Artery / Q000000981:diagnostic imaging / Q000503:physiopathology*