Deep hemorrhage related to dural arteriovenous fistula

Case contributed by Prof Peter Mitchell


Sudden onset RIGHT hemiplegia while traveling.

Patient Data

Age: 71
Gender: Male

Left thalamic hemorrhage surrounds a partially thrombosed vessel with connections to the deep venous system. Edema surrounds the varix.

Large venous structure with varix lying at site of hemorrhage.


Large midline dural AVF with extensive internal and external carotid as well as vertebral feeders including:

Bilateral posterior division middle meningeal arteries - left larger than right, moderate tortuosity, long pathway to fistula(s).

Likely bilateral occipital - but relatively minor cf MMA supply.

Bilateral marginal tentorial branches of the internal carotid arteries - right markedly enlarged, left mildly enlarged with only minimal flow to the DAVF.

Posterior meningeal artery arising from vertebral artery.

Venous drainage into the vein of Galen with reflux into the ectatic internal cerebral vein and basal vein of Rosenthal.


Large midline positioned dural AVF posterior to the splenium of the corpus callosum with extensive internal and external carotid arterial feeders and reflux into the ectatic internal cerebral vein and basal vein of Rosenthal.

High-grade dural AVF grade 4 Cognard classification.

The DAVF of the tentorial incisura characterized previously, receives supply predominantly from bilateral middle meningeal arteries, left posterior meningeal artery, bilateral tentorial (right greater than left) marginal tentorial arteries and the internal carotid arteries, and occipital arteries via transosseous branches. Venous drainage with large venous varicosity which abuts the area of left thalamic hemorrhage shown on CT and MR.A 6Fr guiding catheter was placed in the right common and then external carotid artery, a Sonic microcatheter navigated over a hybrid microwire into the posterior division right middle meningeal artery feeder at the nidus.

Onyx injection with arterial, nidus obliteration.

The second injection was into the left middle meningeal artery, largest superior of the 3 posterior divisions. Sonic microcatheter placed alongside the falx. Good embolization, reaching fistulas, retrograde opacification of other arterial feeders, with penetration to the level of veins.

Final angiographic runs demonstrate complete obliteration of the nidus from the external carotid artery and internal carotid artery feeders, with no arteriovenous shunting. Injection of the left vertebral artery at the end of the procedure demonstrated persistent opacification of fistulas from the posterior meningeal branch of the left vertebral artery-opacification was markedly slowed,

There has been further resolution of the edema surrounding the varix and hemorrhage in the left thalamus, and the thrombosed varix and draining veins have further decreased in volume, and demonstrate more mature fibrotic signal characteristics. There is no hydrocephalus. There is no evidence of recanalization.


Further maturation of the thrombosed varix and fistula that had presented with left thalamic hemorrhage


Case Discussion

Deep tentorial incisura DAVF with cortical venous drainage, connection to deep cerebral veins, and varicosity.  Hemorrhage occurred around the venous varix in this case.  Onyx embolization via the meningeal supply obliterated the fistulas, and secondarily the varix.  Follow up imaging with MRI, and DSA confirmed complete angiographic cure.  The patient made a complete recovery.

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Case information

rID: 33504
Published: 23rd Feb 2015
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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