Venous stroke with intracranial dural arteriovenous fistula

We present a 51-year-old man who developed a biphasic clinical course with an initial myelopathy followed by a lower brainstem syndrome caused by intracranial dural arteriovenous fistula. Brain magnetic resonance imaging (MRI) on T2-weighted imaging demonstrated an extended high signal intensity lesion in the upper cervical cord, medulla oblongata, and lower pons. Cerebral angiography disclosed a fistula between the left external carotid artery (ECA) and the left superior petrosal as well as sigmoid sinuses. There was retrograde venous drainage from the left superior petrosal sinus to the perimedullary cervical veins, leading to venous congestion and venous infarct. Transarterial and then transvenous embolisations were performed and successfully abolished the fistula.