Glucocorticoid Induced Paraplegia in a Patient with Intracranial Dural Arteriovenous Fistula: Case Report

BACKGROUND: Glucocorticoid inducing paraplegia has been reported and regard as a diagnostic clue for spinal dural arteriovenous fistulas (DAVFs). Intracranial DAVF in the posterior fossa draining into the perimedullary venous system can induce congestion of spinal cord while often be misdiagnosed and treated with steroid. CASE A 54-year-old woman presented progressive bilateral extremities weakness, bowel and bladder symptoms. A cervical MRI showed a longitudinally extensive spinal cord lesion from medulla oblongata to level of T4. A diagnose of NMO and cervical spondylopathy was made. On hospital day 2, methylprednisolone was prescribed at dose of 1g intravenous daily. After that, the patient experienced acute paraplegia. Treatment was stopped. And the patient improved on the hospital day 6, almost returned to her initial state. So the diagnosis of SDAVF was suspected. Spinal angiography was performed but the result was normal, and cerebral angiography demonstrated an DAVF fed by the right meningohypophyseal trunk and drain through right petrosal vein and into perimedullary venous system. Operation was performed successfully and the fistula was obliterated. The patient experienced an improvement of weakness and incontinence. We reported a case of intracranial DAVF with acute paraplegia response to intravenous glucocorticoid DAVF can also lead venous congestion of the spinal cord, which induce similar clinical manifestation with spinal DAVF, the MRI examination of spinal cord can also find cord edema and typical enlarged medullary veins.

bladder symptoms. A cervical MRI showed a longitudinally extensive spinal cord lesion from medulla oblongata to level of T4. A diagnose of NMO and cervical spondylopathy was made. On hospital day 2, methylprednisolone was prescribed at dose of 1g intravenous daily. After that, the patient experienced acute paraplegia. Treatment was stopped. And the patient improved on the hospital day 6, almost returned to her initial state. So the diagnosis of SDAVF was suspected. Spinal angiography was performed but the result was normal, and cerebral angiography demonstrated an DAVF fed by the right meningohypophyseal trunk and drain through right petrosal vein and into perimedullary venous system. Operation was performed successfully and the fistula was obliterated. The patient experienced an improvement of weakness and incontinence.

CONCLUSIONS:
We reported a case of intracranial DAVF with acute paraplegia response to intravenous glucocorticoid therapy.Intracranial DAVF can also lead venous congestion of the spinal cord, which induce similar clinical manifestation with spinal DAVF, the MRI examination of spinal cord can also find cord edema and typical enlarged medullary veins. Postoperatively, the patient experienced an improvement of weakness and incontinence.
The control angiography showed that the DAVF disappeared, (Figure 3) and MRI indicated a remission of the cord edema.

Discussion And Conclusion
To our knowledge, this is the first report about a case of glucocorticoid induced paraplegia in patient with intracranial DAVF with perimedullary drainage. A retrospective study has suggested intravenous methylprednisolone could cause immediate worsening of motor and sensory symptoms in patients with spinal DAVF2. In our case which was not spinal DAVF but intracranial DAVF draining into perimedullary venous system, we also found the worsening of paraplegia with glucocorticoid. The similar phenomenon happened to patient with spinal DAVF was thought to be caused by the rapid infusion of saline solution with glucocorticoid which could result in an increase in volemia and venous pressure3. This may also occur in patients with intracranial DAVF, as long as the drainage is into perimedullary venous system which results venous congestion of the spinal cord. This kind of DAVF, of which the pathophysiological mechanism is similar with that of spinal DAVF, would be located at petrous region, tentorium or foramen magnum4. Although experienced neurologists will consider the diagnosis of spinal DAVF when face the typical abnormal void signals on MRI, intracranial DAVF can also lead to spinal myelopathy which is really rare but also should be considered. If a patient experienced acute paraplegia following glucocorticoid 5 administration and no abnormality was found on spinal angiography, cerebral angiography would be necessary. We hope our case will inform the clinicians about the appropriate administration of glucocorticoid in patients with spinal DAVFs and intracranial DAVFs with perimedullary venous drainage.
It is important to recognize that intracranial DAVFs can also cause spinal myelopathy.
Considering of worsening of myelopathic symptoms following intravenous glucocorticoid, the diagnosis of spinal DAVFs or intracranial DAVFs should be suspected.

Declarations
Ethics approval and consent to participate Not applicable Consent for publication A written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the corresponding author.

Availability of data and material
All data analyzed during this study are included in this article.

Competing interests
The authors declare that they have no competing interests.    CAREchecklist.docx