A 77-year-old male with a recent syncope-related fall and closed head injury presented with gradually worsening isolated right upper extremity monoparesis. The fall occurred 1 month before presentation. On examination, the patient demonstrated 4/5 strength in his right upper extremity, with no additional neurologic deficits. Noncontrast head CT demonstrated bilateral mixed density convexity subdural hematomas [22 mm on the left and 14 mm on the right; and ]. The patient underwent a left craniotomy for evacuation of the larger hematoma, in conjunction with bilateral MMA embolization as primary treatment for the right convexity subdural hematoma in addition to limiting potential recurrence along the left convexity. Intraprocedural digital subtraction angiogram revealed two Cognard Grade III DAVFs, one arising from the parietal branch of the right MMA draining into an occipital cortical vein, and the second arising from the temporal branch of the left MMA draining into the vein of Labbe [-]. Given the presence of cortical venous reflux and associated risk of future intracranial hemorrhage, treatment of the fistulae was indicated. This was approached in two staged procedures. Following an uncomplicated left MMA embolization (frontoparietal branch), the incidental findings were discussed with the patient and he underwent a second stage embolization for the DAVF on a later date. During the second stage, a more prolonged infusion of liquid embolic was employed to ensure penetration into the recipient cortical venous outflow, resulting in nonopacification of the aforementioned fistulae. The postoperative course was complicated by seizures which resolved with uptitration in antiepileptic medications. At 6-month follow-up, there was complete resolution of the patient’s presenting symptoms and surveillance CT demonstrated no residual SDH.
A 59-year-old male with a recent fall and closed head injury presented with progressively worsening headaches. The fall occurred 9 days before presentation. On examination, no neurologic deficits were found. Noncontrast head CT demonstrated a 5 mm left convexity CSDH []. He underwent burr hole evacuation and was discharged on the subsequent day. He presented again on postoperative day 6 with recurrence of his headaches. Noncontrast head CT demonstrated recurrence of the left convexity subdural hematoma []. He subsequently underwent a left craniotomy for evacuation. He was discharged on postoperative day 2 with no postprocedural complications. At 1-month follow-up, he continued to complain of severe headaches. Surveillance CT demonstrated a new 27 mm right convexity mixed density subdural hematoma [ and ]. He subsequently underwent right MMA embolization as primary treatment. Intraprocedural digital subtraction angiogram revealed a Cognard Grade III cribriform plate DAVF supplied by the right ophthalmic artery draining into a right frontal cortical vein [ and ]. The right MMA temporoparietal and frontal branches were embolized with n-BCA glue. Follow-up was arranged to treat the DAVF at a later date and he was discharged the following day. The patient was subsequently lost to follow-up, but presented to the emergency department 4 months later with diplopia and a right abducens nerve palsy. Noncontrast head CT demonstrated significant reduction in size of the previously embolized right convexity subdural hematoma. He was admitted and underwent attempted endovascular treatment of the DAVF. Catheterization of the arterial and venous sides of the fistula achieved suboptimal positioning for liquid embolic embolization and so he underwent a right craniotomy for surgical ligation of the fistula. The patient experienced no postprocedural complications. At 2-week follow-up, there was complete resolution of his presenting symptoms and surveillance CT demonstrated no residual SDH.