Cerebral dural arteriovenous fistula (DAVF) with intracerebral hemorrhage

There is a large (45 mm) acute hematoma in the region of the left insula/ basal ganglia extending superiorly into the left frontal white matter. Inferiorly the hematoma is in close proximity to the MCA trifurcation. No unequivocal aneurysm can, however, be identified on the non-contrast CT. Intraventricular extension is evident into the left lateral ventricle. There is mass effect with effacement of the of the lateral left lateral ventricle and 3 mm midline shift to the left. There is also a early effacement of the basal cisterns. No other focal cerebral lesions. The contents of the posterior fossa appear normal. No osseous abnormality within the skull base or calvarium.

CONCLUSION:

Large acute hemorrhage within the left basal ganglia/insula tracking superiorly into the frontal white matter. There is moderately severe mass effect with midline shift and early effacement of the basal cisterns. Clearly in a patient of this age an underlying vascular malformation or aneurysm are highly likely and dedicated intracranial vascular imaging will be required.

No defininte AVM or DAVF, but the presence of a prominent vessel at the superior margin noted and further investigation recommended.

Indication: Patient with a large left basal ganglia hemorrhage extension to the ventricles and right sided weakness. CTA no convincing AVM or DAVF. Patient was transferred from ICU intubated after placement of EVD for diagnostic angiography with view to intervention.

Technique & Findings:

A left parietal DAVF at the left lateral wall of the superior sagittal sinus is identified receives supply predominantly from middle meningeal branches of the left > right with a compact nidus of fistulas, and rapid arteriovenous shunting with drainage to the dilated cortical veins including vein of trolard & then to the superior sagittal sinus. No other significant external carotid supply. No supply from the internal carotids or vertebral arteries bilaterally. No aneurysms or evidence of arteriovenous malformations. Conventional aortic arch. 

The lesion was distal to the site of bleeding but given the high grade Davf and risk of further bleeding for onyx embolization. A 6Fr guiding catheter was placed in the external carotid artery, Apollo microcatheter navigated over microwire into the left MMA feeder just proximal to the nidus. Single pedicle Onyx 34 injection achieved angiographic complete obliteration. Superior sagittal sinus continue to fill normally.