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.
We report a case of a 23-year-old male, known case of Down’s syndrome, who presented to our Emergency Department with a complaint of severe headache for three days. It was accompanied by nausea, vomiting, and confusion. There was no history of trauma, seizures, loss of consciousness, change in vision, or relevant signs of virus infection. He was not on any regular medications. His medical background included surgical closure of ventricular septal defects in his childhood. There was no past medical or family history of coagulopathies.\nOn examination, his Glasgow coma score was 14, with normal vital signs. On neurological examination, the patient was confused, with dense right-sided hemiparesis. Liver function test, prothrombin time, partial thromboplastin time, and international normalized ratio were all within normal range. The brain CT scan revealed left-sided subacute SDH with a 12 mm midline shift and uncal herniation ().\nThe patient underwent emergent left-sided craniotomy and SDH evacuation. The blood evacuated was a mixture of dark stained blood and clots. Post-surgery, the patient’s consciousness level returned to normal, and he regained full power in all limbs. His post-operative CT scan showed optimal evacuation of the left-sided hematoma. There was also a new finding of a small right-sided SDH in the parietal region with no significant mass effect (). The CT scans review showed hyperdense areas in the transverse and sigmoid sinus; this raised suspicion of thrombosis. Magnetic resonance venography (MRV) confirmed the diagnosis of CVST in the right transverse and sigmoid sinuses with loss of flow signal ().\nClinically, the patient made an excellent post-operative recovery. After the diagnosis of CVST, we obtained neurology opinion and considered it risky to commence therapeutic anticoagulation in the early post-operative phase. He was started on a prophylactic dose of low molecular heparin. The patient was discharged home one week after surgery. Subsequently, he was readmitted electively two weeks later and was commenced on Apixaban. He was followed up regularly in outpatients and was asymptomatic.\nThe patient re-presented three months later complaining of a headache and recurrent vomiting, with normal consciousness levels. His repeat brain CT showed recollection of hematoma in the left subdural space (). An updated MRV revealed an interval shrinkage of the thrombus in the right sigmoid venous sinus; however, the reduced flow was seen through the sinus. The medical decision was to stop the anticoagulation, and the patient underwent reopening of the left-sided craniotomy and evacuation of the recurrent SDH. He recovered well after surgery, and we elected not to restart anticoagulation and follow-him clinically.\nThe patient remains clinically well. Interval MRI and MRV scans at six months show complete resolution of the SDH, with residual partial thrombosis of the right sigmoid sinus; however, the sinus is patent, and the venous flow is restored ().