1. Spinal arteriovenous malformation with huge subarachnoid hemorrhage associated with tethered cord and lipoma Antônio Santos de Araújo Júnior 1, Pedro Alberto Arlant 1, Arnaldo Salvestrini Júnior 1, Marcos Fernando de Lima Docema 2, Rogério Tuma 3, Mirella Martins Fazzito 3, Jose Guilherme Mendes Pereira Caldas 4. 1. Neurosurgeon, Sírio-Libanês Hospital; 2. Neuroradiologist, Sírio-Libanês Hospital; 3. Neurologist, Sírio-Libanês Hospital; 4. Interventional Neuroradiologist, Sírio-Libanês Hospital Background: The coexistence of spinal arteriovenous malformation (SAVM) with congenital abnormalities is relatively common. However, the association of a SAVM and tethered cord with lipoma is extremely rare. We report an adult patient with this combined anomaly, who presented a huge subarachnoid hemorrhage. Case description: A 47 year-old Caucasian man presented suddenly an intense low back pain with right leg pain, followed short after by anesthetic paraplegia. Ten hours later he was brought to our hospital. On neurological examination there was a flaccid paraplegia with dense sensitive level T4; spinal MRI revealed a large spinal subarachnoid hemorrhage from C7 to S1, with spinal cord compression and myelomalacia from D4 to D6. Further examination showed a tethered cord, with lower conus medullaris at L4, and a sacral lipoma at S1-S2 level. Intervention: Patient was promptly submitted to a T4-T6 laminectomy with durotomy and hemorrhage drainage, followed a day after by SAVM successfully embolization. Patient exhibited sensory improvement during the two postoperative weeks, but remained paraplegic up to now. Conclusion: Recognition of co-existing vascular anomalies with tethered cord and lipomas is important to identify the symptomatic disease and to perform a tailored treatment. Patients harboring these combined anomalies should not correct the tethered cord before complete SAVM embolization, in order to prevent neurological deterioration by venous hypertension. References 1.Rajeev K, Panikar D. Dural arteriovenous fistula coexisting with a lumbar lipomeningocele. Case report. J Neurosurg Spine. 2005 Nov;3(5):386-9. 2.Poisson A, Vasdev A, Brunelle F, Plauchu H, Dupuis-Girod S; French Italian HHT network. Acute paraplegia due to spinal arteriovenous fistula in two patients with hereditary hemorrhagic telangiectasia. Eur J Pediatr. 2009 Feb;168(2):135-9. Epub 2008 Nov 20. 3.Rodesch G, Hurth M, Alvarez H, Tadie M, Lasjaunias P. Spinal cord intradural arteriovenous fistulae: anatomic, clinical, and therapeutic considerations in a series of 32 consecutive patients seen between 1981 and 2000 with emphasis on endovascular therapy. Neurosurgery. 2005 Nov;57(5):973-83. Figure 1: (A-C) Spinal MRI showing a large spinal subarachnoid hemorrhage from C7 to S1, with spinal cord compression and myelomalacia from D4 to D6; (D) Lumbosacral spine MRI showing a serpiginous lesion with a ‘flow-void’ up to L5 to S3 (suggestive of spinal AVM), connected to a sacral lipoma. Figure 2: (A) Intraoperative microscopic view after T4-T6 laminectomy, durotomy and hemorrhage drainage, with re-establishment of the normal oscillatory spinal cord motion; (B) Subarachnoid saline solution irrigation with a urethral catheter to certify total hemorrhage drainage. AB C D A B Figure 3: Spinal arteriovenous malformation, located at the lumbosacral level.