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Dural arteriovenous fistula

Case contributed by Dr Bruno Di Muzio

Presentation

Sudden collapse on a street, GCS 7.

Patient Data

Age: 50 years
Gender: Male
CT

CT Brain (Emergency department)

In the left occipital lobe, 16 mm parenchymal haematoma complicated by a moderately left convexity and tentorial subdural haematoma that measures up to 8 mm thick with the parafalcine component. There is so infratentorial subdural haematoma on the right side. Midline shift to the moderate midline shift to the right associated uncal herniation, right ventricular trapping. Skull vault is unremarkable. No cephalhaematoma detected. 

CT

CT Brain (5 days after drainage/decompression craniectomy)

Expect changes post left craniectomy with reduced left convexity subdural haemorrhage and improved mass effect on the left cerebral hemisphere. No new focus of haemorrhage.

MRI

MRI Brain (10 after hemicraniectomy)

Left-sided craniectomy and overlaying extra-axial collection with fluid and blood products are again demonstrated. The left occipital lobe intraparenchymal haemorrhage is unchanged in size and amount of surrounding vasogenic oedema. There is a slightly prominent cortical vessel that runs close to the posterior superior sagittal sinus and shows a bulkier component abutting the left occipital parenchymal haemorrhage; also, some signs of high flow within the superior sagittal sinus is noted on the MRA TOF. Additionally, there is the prominence of the left posterior auricular artery with apparent transosseous branches to the left transverse sinus. The haematomas along the cerebral falx, tentorium, prepontine cistern, floor of the anterior cranial fossa on the left, and overlaying the left temporal lobe have remained overall unchanged compared to the last CT. Rightward midline shift of 6 mm is stable. Circle of Willis MRA is degraded by motion artefacts and of limited assessment.

Conclusion: Imaging features raise the suspicion for an underlying vascular malformation, particularly a left dural arteriovenous fistula. Further DSA study is recommended. Intracranial haematomas are overall unchanged since the previous scan.

DSA (angiography)

Angiography

There is arteriovenous shunting occurring a focal point just above the left transverse sinus, the dysplastic vein draining parallel to the sinus posteriorly, then turning superiorly to run into para sagittal course some 5 -10 mm from the Then a 180 degrees turn into the superior sagittal sinus at the vertex. Arterial supply is from trans-osseous branches of the occipital artery, the ascending pharyngeal artery, there was retrograde opacification of the dysplastic appearing posterior division of the MMA - likely a previous supplied by having been sacrificed as part of the decompressive craniectomy flap. There is a large venous aneurysm more varix at the site of the occipital intraparenchymal haematoma. The vein above this is severely dysplastic. No arterial aneurysms are shown. There is arterial supply from the left posterior inferior cerebellar artery, a midline branch presumed meningeal given the supply to this area which is above the tentorium, and there is also some supply from a similar branch from the right posterior inferior cerebellar artery. There is no separate supply from the internal carotid artery

DSA (angiography)

Angiography (after dAVF surgical exclusion)

The previously demonstrated dural AVF has been excluded from the circulation, with no evidence of residual arterio-venous shunting. The left femoral arteriotomy was closed using a 6-French Angio-Seal device. The procedure was well tolerated. No angiographic complications identified. 

Case Discussion

This case demonstrates a patient presenting with spontaneous intracranial haemorrhage that on further MRI investigation showed to be related to a dural arteriovenous fistula. Angiography has confirmed and better characterised the that as a high-grade dural arteriovenous fistula, directly into a leptomeningeal vein, with a venous aneurysm and varicosity, also with a paradoxical supply from beneath the tentorium from PICA. 

The patient then was treated surgically and complete exclusion of the dural AVF from the circulation has been confirmed on the last angiogram.

Angiography images courtesy of the RMH radiology neuro intervention team. 

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Case information

rID: 54662
Case created: 20th Jul 2017
Last edited: 3rd Sep 2017
Inclusion in quiz mode: Included

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