Dural AVF with Progressive Edema and Mass Effect
A 51-year-old diabetic and hypertensive male presented with a 1 month history of progressive headache and blurred vision. His initial MRI brain (Fig. 67.1) revealed a small right temporal lobe hematoma with extensive surrounding edema involving the right temporal lobe and extending into the posterior frontal and the parieto-occipital region. MRI and MRV revealed right transverse sinus thrombosis along with multiple dilated serpiginous venous channels in the right temporal lobe. On interval repeat imaging (Fig. 67.2), there was further progression in the edema with mass effect resulting in the effacement of the right lateral ventricle, sphenoidal, and operculo-insular parts of the Sylvian cistern and the crural cistern. There was midline shift of approximately 5 mm along with early uncal herniation. Cerebral angiography (Fig. 67.3) revealed a right Borden type 3 tentorial dural AV fistula with feeders from the petrosal branch of the middle meningeal artery, transosseous branch of the occipital artery, and the neuromeningeal division of the ascending pharyngeal artery. The feeder from the petrosal branch of the middle meningeal artery was diminutive in caliber as compared to the other feeders. The venous drainage was redirected through pial cortical vein into the superior sagittal sinus. There was no forward flow through the right transverse sinus. Another small pial AVM nidus was seen in the right temporal lobe with feeders from the inferior division of the right MCA and venous outflow redirected through the cortical vein into the superior sagittal sinus.