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.
This 67-year-old male man has had a progressively worsening pain on the left cranium over 2 weeks that intractable to some analgesics. There was no recent head trauma or other medical disease in his history. On admission, the general physical and neurologic investigations were not remarkable. Routine laboratory evaluations including coagulation profiles and platelet function were within normal limits.\nBrain computed tomography (CT) scans revealed an isodense left-sided CSDH with marked cerebral shifting (). There was no evidence of source of this hemorrhage with temporal predilection on the CT angiogram. On magnetic resonance (MR) image subsequently obtained, the abnormal intensity within the subarachnoid space and the brain parenchyma was not visible. The patency without steno-occlusion in both transverse and sigmoid sinuses was clearly delineated on T2-weighted sequences (). This patient has received a trephination and SDH drainage, after that he was sent home with resolution of headache. Approximately 2 weeks later, however, he developed an excruciating pain in the temporal and parietal regions with recurrence of subdural collection. The site and density of hematoma was similar to the first presentation (). He was immediately returned for subdural irrigation and decompression through the prior burr-holes. The patient's clinical course was not eventful, but he complained of a mild headache again. Follow-up CT scanned just prior to discharge was strikingly for the newly-formed thin hematoma at the operative site (). Another evacuation of this subacute subdural clot was not deemed to be necessary.\nAt this time, an active intervention was sought for this patient who had an intractably recurring CSDH. On the 7th day after the second surgery, angiography was performed to rule out an occult vascular lesion. A flow-guided type microcatheter (Prowler 10™, Cordis Neurovascular, Miami Lakes, FL, USA) was positioned in the main trunk of the MMA for selective angiography. The frontal and parietal branch of the MMA was appeared normally, and the abnormal membrane staining on the affected side was not detected. A left external carotid angiogram disclosed a dural AVF between the petrosquamosal branch of the MMA and the transverse-sigmoid sinus without retrograde cortical venous draining. The AV shunt had no connection to the internal carotid artery and its branches. It was suggested that the bleeding from the draining venous system of the dural AVF led to refractory CSDH. The microcatheter was introduced into the petrosquamosal branch of the MMA, thereafter polyvinyl alcohol particles ranging 150 to 250 µm were distally injected (). After trans-arterial obliteration of the feeder and fistula, the AV shunt disappeared. The recurrent hematoma of this patient did not increase, and his complaints of headache gradually subsided. The brain CT at one year following the embolization therapy revealed complete regression of the subdural hematomas ().