Spinal intradural arteriovenous fistulas acquired in late adulthood: absent spinal venous drainage in pathogenesis and pathophysiology. Report of two cases.

Intradural spinal arteriovenous fistulas (AVFs), a subtype of spinal arteriovenous malformation in which there is a direct communication between a spinal artery and a vein on the cord surface or in the subarachnoid space, are generally considered to be congenital lesions caused by maldevelopment of the embryonic vascular system. The authors present the cases of two patients with acquired AVFs of the terminal filum. In each patient an AVF between the distal segment of the anterior spinal artery and its accompanying vein on the terminal filum developed within 1 year of repeated lumbar myelography that had demonstrated no evidence of abnormal vascularity. In both patients spinal arteriography demonstrated the absence of medullary venous drainage in the thoracolumbar region, which, combined with the arterialized venous input from the AVF, permitted the development of venous congestion and myelopathy. The involved segment of the terminal filum was excised; in vitro microarteriography and the histopathological examination demonstrated a single, simple arteriovenous connection in both patients. The findings in these cases indicate that intradural AVF can spontaneously arise in later life. The development of these lesions and/or their clinical manifestation may require not only the presence of the AVF, but also deficiency of medullary spinal venous drainage. The epidemiology and anatomy of intradural AVFs are compatible with an acquired origin in many cases.