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Fig 4. Coronal digital subtraction angiography (DSA) projection (A) and multiplanar reformatted contrast-enhanced MR angiography (CE-MRA) of the early phase (B) and late phase (C and D) in a 55-year-old male patient (case 8) with a spinal dural arteriovenous fistula (diagnosed on the basis of DSA). On the DSA projection image (A) the supplying segmental artery (SA) (asterisk), the great anterior radiculomedullary artery (ie, the Adamkiewicz artery [AKA]) (large white arrow), and the anterior spinal artery (ASA) (white arrowhead) are shown. The CE-MRA of the early phase (B) shows the supplying SA (asterisk) and the AKA (large white arrow). Regarding the anterior midline enhancement in the early phase (B) above as well as below the connection of the AKA with the ASA, this is most likely to be enhancement of both the ASA (white arrowheads) and the anterior median vein (AMV) (black arrowheads). The late-phase CE-MRA (C) shows diminished signal intensity of the AKA (large white arrow), in contrast to the anterior midline enhancement, which is clearly increased compared with the early phase (B) as a result of increased venous enhancement. The midline enhancement seen in the late phase (C and D) is most likely to be a combination of AMV (black arrowheads) and ASA (white arrowheads) enhancement. In addition, the great anterior radiculomedullary vein (GARV) (large black arrow) is displayed in the late phase of the CE-MRA (D). Note that the signal intensity of the GARV and midline enhancement is equal (D). Furthermore, there is enhancement of the venous plexus (small black arrows) in the late phase (C and D), which is not seen in the early phase CE-MRA image (B). Note that the cephalad enhancement above the connection of the AKA with the ASA is only depicted on the CE-MRA images (B and C), and not in the DSA image (A). Note that there is more background enhancement in the CE-MRA images.
