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Acute clinical deterioration of a patient with spinal dural arteriovenous malformation after lumbar puncture and steroid treatment – a case report and discussion of possible reasons

Julia Walch, Anita Prochnicki, Dominik Zieglgänsberger, Stefan Haegele-link, Barbara Tettenborn, Claudia Hader, Johannes Weber & Raoul Heilbronner

abstract Introduction
Spinal dural arteriovenous malformations are rare causes of subacute onset of progressive spinal symptoms including paraparesis, sensory deficits, sphincter and bladder disturbances and back pain. The pathophysiology of a spinal dural arteriovenous fistula (SDAVF) is venous hypertension and a decrease of arterial supply of the spinal cord causing venous congestion and therefore leading to progressive necrotizing myelopathy. Neurosurgical or interventional treatment is required as soon as possible.
Case description and disease course
We present a 56 year-old women with a 3 weeks history of bladder and bowel sphincter dysfunction, progressive parapareses and muscle pain in both legs. Lumbar puncture was performed to exclude an infectious or immunologic etiology for the white matter alterations seen in the MRI longspine. Also a high-dose steroid treatment was initiated. Some hours later an acute deterioration occurred and the patient developed paraplegia of the lower extremities. Finally the diagnosis of a SDAVF was made the day after and neurosurgical treatment was initiated immediately.
Discussion
There are descriptions in the literature about deterioration of SDAVFs following lumbar puncture directly after penetrating the dura, which was not the case in our patient. It is known that steroid treatment can cause a deterioration in these patients too, but the pathophysiology behind is not completely understood.
Conclusion
- We want to increase awareness of this rare but treatable cause of subacute progressive myelopathy as an important differential diagnosis.
- We suggest not to perform a lumbar puncture in patients suspicious for SDAVF.
- The impact of steroid treatment in SDAVF patients is unclear but is probably better to be avoided.
   
citation Walch J, prochnicki a, Zieglgänsberger D, haegele-link s, Tettenborn B, Hader C, Weber J, & heilbronner r (2016). Acute clinical deterioration of a patient with spinal dural arteriovenous malformation after lumbar puncture and steroid treatment – a case report and discussion of possible reasons. In .
   
type conference paper/poster (English)
name of conference Jahrestagung der Schweizerischen Neurologischen Gesellschaft (Basel)
date of conference 29-9-2016
contact Julia Walch