Angiographically Silent Ruptured Dural Arteriovenous Fistula Presenting As Subdural Hematoma

Area of Science:

• Neurology
• Vascular Surgery
• Radiology

Background:

• Dural arteriovenous fistulas (dAVF) are abnormal connections between dura mater arteries and veins.
• These malformations typically present with symptoms like headaches and can lead to severe neurological deficits.
• Diagnosis usually involves CT angiography (CTA) and catheter angiography.

Observation:

• A patient presented with a headache and a large holohemispheric subdural hematoma without a history of trauma.
• CT angiography revealed abnormal vessels near the temporal lobe, but a subsequent cerebral angiogram showed no early venous drainage.
• Surgical exploration identified an aberrant connection between a cortical vein and the middle meningeal artery.

Findings:

• The aberrant vascular connection was successfully ligated during surgery.
• This case demonstrates a rare instance where a ruptured dural arteriovenous fistula was radiographically occult on cerebral angiography.
• The subdural hematoma was evacuated, resolving the patient's symptoms.

Implications:

• Ruptured dural arteriovenous fistulas can present atypically, posing diagnostic challenges.
• Advanced imaging and intraoperative findings are crucial for diagnosing and treating such rare vascular malformations.
• This case underscores the importance of considering dAVFs even when initial angiography is negative.