Presentation
Chronic headache. Pulsatile tinnitus in left ear.
Patient Data
There is evidence of a vascular lesion measuring ~ 10 x 9 mm in the posterior fossa on the lateral aspect of the left transverse sinus. The lesion is seen to receive multiple dilated and tortuous feeding arteries from the left superficial temporal artery, left middle meningeal artery, left posterior auricular artery and the left occipital artery. Multiple arterial feeders arising from the left posterior auricular artery and the left occipital artery are seen to pass through the diploic space of the left occipital bone. No obvious feeder from Internal carotid and vertebro-basilar circulation seen. Multiple flow voids are noted in the left cerebral hemisphere on T2W images which represent dilated leptomeningeal veins. These flow voids are better appreciated on SWI. On post contrast T1W sequences, filling defects are noted in the region of the confluence of sinuses, left transverse sinus and the left sigmoid sinus which suggests chronic dural venous sinus thrombosis. No evidence of intracranial haemorrhage or infarct was seen.
Case Discussion
Intracranial dural arteriovenous fistulae are abnormal communications between dural arteries and dural venous sinuses, cortical veins or meningeal veins. This case demonstrates a dural arteriovenous fistula in the left transverse sinus in the setting of chronic dural venous sinus thrombosis, which is a known predisposing factor. Multiple feeders from the branches of the external carotid artery are seen to supply the fistula. Cerebral angiography would be the next step for classification and management of the dural arteriovenous fistula.
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