A 45-year-old man was admitted for a progressively worsening headache over 2 weeks. He denied history of recent head trauma or anticoagulation and antiplatelet medication. General and neurologic examinations were not remarkable on admission. Routine laboratory investigations including coagulation profiles and platelet function were within normal limits. Head computed tomography (CT) on admission revealed an isodense CSDH on the right hemisphere with mild midline shift (Fig. a). A CT angiography (CTA) was performed to rule out any intracranial vascular malformation. A DAVF was noticed at the transverse sinus with dilated cortical venous drainage (Fig. b). So, a digital subtraction angiography (DSA) of the external carotid artery and DAVF embolization was planned.\nNo anomaly was noticed during selective angiography of the internal carotid and vertebral arteries and the left external carotid artery. Selective angiography of the right external carotid artery showed that the DAVF was located at the transverse sinus and fed by posterior branch of the middle meningeal artery (MMA), the occipital artery, and the posterior meningeal artery and drained to the occipital cortical veins with venous ectasia (Fig. a-b). The DAVF was classified as type IV according to the Cognard classification. The embolization was performed via the MMA. The Headway duo catheter was used and accessed to the DAVF, and Onyx was injected until the shunt disappeared (Fig. c-d). The patient experienced an uneventful recovery. His CSDH gradually resolved in 1 month (Fig. ). No neurologic deficit was noticed.\nA PubMed search of published studies written in English and Chinese was conducted on June 30th, 2017. The following key words were used in relevant combinations: dural arteriovenous fistula, dural arteriovenous malformation, subdural hematoma, subdural haematoma, subdural hemorrhage, and subdural haemorrhage. The reference lists of the identified articles were also manually searched for additional studies. Studies of which full text could not be obtained or those without sufficient individualized description of the isolated SDH cases mixed in larger case series were excluded.\nFinally, 13 articles containing 14 patients were identified [–]. In all 15 patients (9 females, 60%) including 1 case in our institution were included for the final interpretation (Table ). The inflicted patients were aged from 27 to 82 years (55.5 ± 8.6).Of note, 12 (80%) of the 15 patients were aged between 40 and 60 years of age, and 8 (53.3%) patients were between 50 and 60 years. Sides of the DAVF or SDH were obtained in 13 patients with 9 (69.2%) located at the left side and 4 at the right side. The intracranial locations of DAVF were anterior fossa (2), middle fossa (2), frontal region (2), parietal region (3), temporal region (2), and occipital region (2). The types of SDH were CSDH (7/15), acute SDH (ASDH) (7/15), and undefined SDH (1/15). Of the 12 patients feeding artery could be identified, MMA was the commonest feeding artery (8/12, 66.7%). Multiple feeding arteries were identified in 3 (25%) patients. The causes of DAVF were only defined in 3 patients (2 iatrogenic and 1 traumatic), with the rest undefined or not mentioned. Cognard classifications (Table ) of the DAVF were reported or deduced from the reports in 12 patients, with type I, type III, and type IV in 7, 2, and 3 patients respectively. The treatment strategies included hematoma evacuation (2/15), CSDH drainage and DAVF embolization (5/15), craniotomy and DAVF resection (3/15), DAVF embolization and hematoma evacuation (1/15), DAVF embolization (2/15), and not applicable or not mentioned (2/15). Of the 12 patients with direct description of outcome, 7 (58.3%) patients were neurological intact, 3 (25%) patients with neurological deficits, and 2 (16.7%) died.
A 59-year-old male patient suffered from rapidly progressive and pulsatile headache over the right parietal region characterized as thunderclap and nausea. He had no fever. These symptoms were followed by generalized seizure. Neurological examination showed a normal level of consciousness. On examination, meningism was seen. The rest of the physical examination was unremarkable. CT scan head was normal. MRI revealed right parasagittal high fronto-parietal subarachnoid hemorrhage with mild gyral edema. MRV showed superior sagittal sinus and bilateral transverse sinus thrombosis [Figures and ]. DSA confirmed [Figures and ] the diagnosis of DST without any potential cause of SAH. Coagulation testing, including prothrombin time, activated prothrombin time, anticardiolipin antibody titer, antiphospholipid antibody titer, homocysteine titer, and levels of protein C and S, antithrombin III, and fibrinogen were all within normal limits and done simultaneously with MRI, MR Venography, DSA within one to two days of admission. Subcutaneous LMW heparin therapy was given. The patient's condition stabilized after nine days of treatment. Oral warfarin maintained an INR of 2.0-3.0. Patient's improvement was clinically satisfactory within six weeks, Repeat DSA done after six weeks was normal, except minimal filling defect. Patient was followed up at two-weeks intervals for three months