A 73-year-old female presented with 2 days of progressively worsening lower extremity weakness. Examination demonstrated 4/5 strength in proximal lower extremities and 5/5 strength distally, hyperreflexia and bilateral Babinski signs. MRI of the cervical and thoracic spine revealed cord signal changes from C5 to T5. She was empirically treated with methylprednisolone for presumed transverse myelitis. The following day strength testing revealed 4-/5 strength proximally, 5/5 distally, and worsening urinary incontinence. The patient underwent a lumbar puncture that day following which her lower extremities strength was 0/5 proximally and 1/5 distally with new complete sensory loss below T10.
Repeat spine MRI revealed persistent signal changes and the presence of flow voids along the cervical spine. SDAVF was suspected, with spinal angiography revealing a single arterial feeder from the right deep ascending cervical artery at the C4-C5 vertebrae. The patient underwent successful embolization of the vessel. Lower extremity strength improved slightly to 2/5 distally and 1/5 proximally at the time of discharge, and to 4/5 distally and 3/5 proximally 3 months later following rehabilitation.