Rapid surgical intervention for acute spinal subdural hematoma triggered by ruptured spinal dural arteriovenous fistula: illustrative case.

backgroundSpinal dural arteriovenous fistulas (dAVFs) are rare vascular malformations that typically cause progressive congestive myelopathy. Hemorrhagic presentations of dAVFs, such as subdural hematomas (SDHs), are exceedingly rare and can lead to acute neurological deterioration. OBSERVATIONS: The authors present a case of spinal SDH secondary to a ruptured spinal dAVF. A 46-year-old woman presented with rapidly progressing paraparesis to complete paralysis within hours, without a history of trauma, anticoagulation, or infection. Thoracic spine MRI revealed an intradural, ventral extramedullary lesion from T4 to T7, consistent with a compressive hematoma. The patient underwent a thoracic laminectomy for evacuation. Intraoperative indocyanine green angiography identified a spinal dAVF near the left T7 nerve root sleeve, which was successfully clipped. At the 9-month follow-up, the patient had significantly recovered with 4/5 strength in her lower extremities. LESSONS: This is the fourth documented instance of a spinal dAVF presenting as a spinal SDH. Clinicians should consider this diagnosis in patients with acute paraplegia, back pain, and sphincter dysfunction, especially without trauma or coagulopathy. Diagnosis may be complicated by angiographically occult lesions due to a hematoma mass effect, making intraoperative imaging essential. Prompt surgical decompression and fistula disconnection can yield significant neurological recovery, as demonstrated in this case and limited literature. https://thejns.org/doi/10.3171/CASE25510.