Spinal Dural Arterio-Venous Fistula: A Vital Differential Diagnosis to Consider for Myelopathy.

INTRODUCTION: Spinal dural arterio-venous fistula (SDAVF) is a rare and underdiagnosed cause of myelopathy which can result in a devastating neurological outcome if not properly managed. CASE DESCRIPTION: We report a case of SDAVF in a middle-aged man with gradual progressively deteriorating myelopathy and associated symptoms. This was first managed as demyelinating disease but was refractory to steroid therapy. Vigilant review of his spinal magnetic resonance imaging (MRI) scans showed dilated perimedullary veins, suspicious for SDAVF. The diagnosis was confirmed with catheter angiography. Neurological symptoms resolved after surgical treatment. DISCUSSION: SDAVF can closely mimic demyelinating conditions such as transverse myelitis or multiple sclerosis. MRI finding of dilated perimedullary veins can be subtle and masked in the late stage, posing a diagnostic challenge for physicians. It is potentially curable after timely treatment. CONCLUSION: Clinicians should maintain a high level of suspicion for SDAVF and actively review all available radiological imaging for clues, particularly when there is a lack of response to treatment for other causes of myelopathy. LEARNING POINTS: Spinal dural arterio-venous fistula (SDAVF) can have clinical and radiological features similar to those of demyelinating disease, often causing a diagnostic dilemma for physicians. Neurological sequalae can be devastating if left untreated.Clinicians should be aware of this rare yet important differential diagnosis for myelopathy and its classic MRI findings (spinal cord oedema and dilated perimedullary veins).The gold standard for diagnosis is catheter spinal angiography. Treatment options include endovascular embolization and surgical ligation of the fistula.