Deep hemorrhage related to dural arteriovenous fistula

Left thalamic hemorrhage surrounds an ectatic vessel with connections to the deep venous system. Edema surrounds the varix.

Large venous structure with varix lying at site of hemorrhage connecting to the vein of galen.

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

Bilateral posterior division middle meningeal arteries (left and right). Moderate tortuosity, and a long pathway to the fistula.

Likely bilateral occipital (left and right) but relatively minor compared to middle meningeal supply.

Bilateral marginal tentorial branches of the internal carotid arteries, right markedly enlarged (lateral, frontal), left mildly enlarged with only minimal flow to the fistula.

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

Conclusions:

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 MRI.

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 (frontal and lateral) at the nidus with Onyx injection and arterial nidus obliteration.

The second injection was into the left middle meningeal artery, the largest superior of the three 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 (not shown) 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.