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      A Case of Spontaneous Acute Subdural Hemorrhage Caused by a Dural Arteriovenous Fistula on the Convexity without Cortical Venous Reflux

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          Abstract

          Bleeding from a dural arteriovenous fistula (DAVF) typically occurs in the form of an intracerebral or subarachnoid hemorrhage. Here, we report a rare case of a DAVF with an acute subdural hematoma (ASDH). A 29-year-old male presented to the emergency department with a complaint of progressing headache and nausea, with no reported episode of head trauma. Non-contrast CT revealed a left ASDH with a moderate midline shift. Digital subtraction angiography revealed a DAVF on the left parietal convexity. The DAVF was fed by the middle meningeal artery and drained into the superior sagittal sinus and the sphenoparietal sinus via the diploic vein without cortical venous reflux. The DAVF was treated with transarterial embolization using 25% diluted n-butyl cyanoacrylate prior to hematoma removal. The bleeding point was confirmed on the inner surface of the dura mater. The patient recovered well without any neurological deficits.

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          The validity of classification for the clinical presentation of intracranial dural arteriovenous fistulas.

          A number of classification schemes for intracranial dural arteriovenous fistulas (AVFs) have been published that claim to predict which lesions will present in a benign or aggressive fashion based on radiological anatomy. We have tested the validity of two proposed classification schemes for the first time in a large single-institution study. A series of 102 intracranial dural AVFs in 98 patients assessed at a single institution was analyzed. All patients were classified according to two grading scales: the more descriptive schema of Cognard, et al. (Cognard) and that recently proposed by Borden, et al. (Borden). According to the Borden classification, 55 patients were Type I, 18 Type II, and 29 Type III. Using the Cognard classification, 40 patients were Type I, 15 Type IIA, eight Type IIB, 10 Type IIA+B, 13 Type III, 12 Type IV, and four Type V. Intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit was considered an aggressive presenting clinical feature. A total of 16 (16%) of 102 intracranial dural AVFs presented with hemorrhage. Eleven of these hemorrhages (69%) occurred in either anterior cranial fossa or tentorial lesions. When analyzed according to the Borden classification, none (0%) of 55 Type I intracranial dural AVFs, two (11%) of 18 Type II, and 14 (48%) of 29 Type III intracranial dural AVFs presented with hemorrhage (p < 0.0001). After exclusion of visual or cranial nerve deficits that were clearly related to cavernous sinus intracranial dural AVFs, nonhemorrhagic neurological deficits were a feature of presentation in one (2%) of 55 Type I, five (28%) of 18 Type II, and nine (31%) of 29 Type III patients (p < 0.0001). When combined, an aggressive clinical presentation (ICH or nonhemorrhagic neurological deficit) was seen most commonly in intracranial dural AVFs located in the tentorium (11 (79%) of 14) and the anterior cranial fossa (three (75%) of four), but this simply reflected the number of higher grade lesions in these locations. Aggressive clinical presentation strongly correlated with Borden types: one (2%) of 55 Type I, seven (39%) of 18 Type II, and 23 (79%) of 29 Type III patients (p < 0.0001). A similar correlation with aggressive presentation was seen with the Cognard classification: none (0%) of 40 Type I, one (7%) of 15 Type IIA, three (38%) of eight Type IIB, four (40%) of 10 Type IIA+B, nine (69%) of 13 Type III, 10 (83%) of 12 Type IV, and four (100%) of four Type V (p < 0.0001). No location is immune from harboring lesions capable of an aggressive presentation. Location itself only raises the index of suspicion for dangerous venous anatomy in some intracranial dural AVFs. The configuration of venous anatomy as reflected by both the Cognard and Borden classifications strongly predicts intracranial dural AVFs that will present with ICH or nonhemorrhagic neurological deficit.
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            Dural arteriovenous fistula on the convexity presenting with pure acute subdural hematoma.

            Non-traumatic dural arteriovenous fistula/malformation (dural AVF/AVM) presenting with pure subdural hematoma (SDH) is relatively rare. We report on a male patient who showed pure acute SDH and was diagnosed as having dural AVF on the convexity near the superior sagittal sinus (SSS), based on angiographic findings. A 27-year-old man was admitted to our hospital due to headache with acute onset. The patient did not have a history of head trauma or injury. Head CT showed an abnormal high-density area on the surface of the cerebral hemisphere on the left side, indicating acute SDH. Angiography during the arterial phase demonstrated that an abnormal artery originating from the left occipital artery was connected with a dural vein and a diploic vein on the convexity near the SSS. We concluded that a dural AVF existed at this area, and that the dural AVF had caused the acute SDH. Dural AVF/AVM which causes non-traumatic SDH is usually accompanied by intracerebral hemorrhage (ICH) and/or subarachnoid hemorrhage (SAH). In contrast, non-traumatic dural AVF/AVM presenting with pure SDH is rare, and our patient represents such a rare case. We should consider dural AVF/AVM and perform angiography if necessary when we encounter a patient showing non-traumatic SDH without ICH and/or SAH.
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              Dural arteriovenous fistula presenting as an acute subdural hemorrhage that subsequently progressed to a chronic subdural hemorrhage: case report.

              Non-traumatic subdural hemorrhage (SDH) caused by dural arteriovenous fistula (DAVF) is rare and is usually accompanied by intracerebral hemorrhage (ICH) and/or subarachnoid hemorrhage (SAH). This report describes a very rare case of DAVF that caused non-traumatic acute SDH without ICH or SAH, which subsequently progressed into chronic SDH.
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                Author and article information

                Journal
                CRN
                CRN
                10.1159/issn.1662-680X
                Case Reports in Neurology
                S. Karger AG
                1662-680X
                2019
                September – December 2019
                21 November 2019
                : 11
                : 3
                : 312-318
                Affiliations
                [_a] aDepartment of Neurosurgery, National Hospital Organization Toyohashi Medical Center, Toyohashi, Japan
                [_b] bDepartment of Neurosurgery, Hamamatsu Rousai Hospital, Hamamatsu, Japan
                Author notes
                *Keita Yamauchi, Department of Neurosurgery, National Hospital Organization Toyohashi Medical Center, 50 Imurecho hamamichigami, Toyohashi, Aichi 440-8510 (Japan), E-Mail keitasbrt0326@yahoo.co.jp
                Article
                504290 PMC6902228 Case Rep Neurol 2019;11:312–318
                10.1159/000504290
                PMC6902228
                31824286
                cf6e0683-5687-49a4-a7ed-88ea229598d1
                © 2019 The Author(s). Published by S. Karger AG, Basel

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                : 30 September 2019
                : 17 October 2019
                Page count
                Figures: 3, Pages: 7
                Categories
                Single Case – General Neurology

                Geriatric medicine,Neurology,Cardiovascular Medicine,Neurosciences,Clinical Psychology & Psychiatry,Public health
                Transarterial embolization,Spontaneous acute subdural hemorrhage,Dural arteriovenous fistula

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