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Peer-reviewedCC BY-NC-ND 4.0Journal of Neurosurgery: Case Lessons

Sacral spinal dural arteriovenous fistula: diagnostic pitfalls and treatment challenges. Illustrative case

  • Thomas Hamre1
  • Ashley Ricciardelli1
  • Ihika Rampalli2
  • Zachary Perry1
  • Alex Flores1
  • Alexander Brenner1
  • Naser Jaleel1
  1. 1Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
  2. 2Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Abstract

BACKGROUND: Sacral spinal dural arteriovenous fistulas (sDAVFs) are rare and easily missed on imaging, especially when supplied by internal iliac branches. Regional vascular anatomy may complicate endovascular treatment approaches.

OBSERVATIONS: A 71-year-old man with symptoms suggestive of spinal myelopathy underwent spinal MRI, which revealed multisegment T2 cord hyperintensity from T7 to L1 without serpiginous flow voids; spinal MR angiography (MRA) findings were negative for sDAVF. On spinal digital subtraction angiography (DSA), selective internal iliac injection identified a right S1 sDAVF originating from a lateral sacral artery branch. Transarterial Onyx embolization formed a plug proximal to the fistula, resulting in failed obliteration. Subsequent microsurgical disconnection via S1 laminectomy appeared successful on intraoperative ICG angiography, but postoperative angiography revealed residual shunting. Reexploration with L5 laminectomy allowed definitive microsurgical ligation, resulting in lasting cure at the 1-year follow-up.

LESSONS: Negative spinal MRI/MRA findings do not rule out sacral sDAVF; complete spinal DSA, including internal iliac injection, is critical if sacral sDAVF is suspected. Sacral angioarchitecture may hinder durable embolization, warranting consideration of upfront microsurgical ligation. With ligation, intraoperative ICG angiography may miss residual flow; immediate postoperative angiography should be best practice. With microsurgical ligation, broad exposures may be ideal for identifying all arterialized veins.

https://thejns.org/doi/10.3171/CASE26220

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Cite

BibTeXRIS
BibTeX
@article{hamre2026sacral,
  title = {{Sacral spinal dural arteriovenous fistula: diagnostic pitfalls and treatment challenges. Illustrative case}},
  author = {Thomas Hamre and Ashley Ricciardelli and Ihika Rampalli and Zachary Perry and Alex Flores and Alexander Brenner and Naser Jaleel},
  journal = {Journal of Neurosurgery: Case Lessons},
  year = {2026},
  month = oct,
  doi = {10.3171/case26220},
  url = {https://doi.org/10.3171/case26220},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Sacral spinal dural arteriovenous fistula: diagnostic pitfalls and treatment challenges. Illustrative case
AU  - Thomas Hamre
AU  - Ashley Ricciardelli
AU  - Ihika Rampalli
AU  - Zachary Perry
AU  - Alex Flores
AU  - Alexander Brenner
AU  - Naser Jaleel
PY  - 2026
DA  - 2026/10/26
JO  - Journal of Neurosurgery: Case Lessons
DO  - 10.3171/case26220
UR  - https://doi.org/10.3171/case26220
AB  - BACKGROUND: Sacral spinal dural arteriovenous fistulas (sDAVFs) are rare and easily missed on imaging, especially when supplied by internal iliac branches. Regional vascular anatomy may complicate endovascular treatment approaches.  OBSERVATIONS: A 71-year-old man with symptoms suggestive of spinal myelopathy underwent spinal MRI, which revealed multisegment T2 cord hyperintensity from T7 to L1 without serpiginous flow voids; spinal MR angiography (MRA) findings were negative for sDAVF. On spinal digital subtraction angiography (DSA), selective internal iliac injection identified a right S1 sDAVF originating from a lateral sacral artery branch. Transarterial Onyx embolization formed a plug proximal to the fistula, resulting in failed obliteration. Subsequent microsurgical disconnection via S1 laminectomy appeared successful on intraoperative ICG angiography, but postoperative angiography revealed residual shunting. Reexploration with L5 laminectomy allowed definitive microsurgical ligation, resulting in lasting cure at the 1-year follow-up.  LESSONS: Negative spinal MRI/MRA findings do not rule out sacral sDAVF; complete spinal DSA, including internal iliac injection, is critical if sacral sDAVF is suspected. Sacral angioarchitecture may hinder durable embolization, warranting consideration of upfront microsurgical ligation. With ligation, intraoperative ICG angiography may miss residual flow; immediate postoperative angiography should be best practice. With microsurgical ligation, broad exposures may be ideal for identifying all arterialized veins.  https://thejns.org/doi/10.3171/CASE26220
SN  - 2694-1902
ER  -