case_images: PMC3604817_01
case_images: Computed tomography scan of brain showing a left frontal large well circumscribed round smooth walled strong and uniformly enhancing hyper dense space occupying lesion with peripheral wall calcification. The lesion demonstrates no obvious perilesional edema with significant mass effect with midline shift
case_images: SNI-4-22-g001.jpg
case_images: PMC3604817_01_SNI-4-22-g001.jpg
case_images: F1
case_images: On computed tomography (CT) scan, a large well circumscribed round smooth walled strong and uniformly enhancing hyper dense space occupying lesion with peripheral wall calcification was found in left frontal lobe [Figure 1].
case_images: (a) T2 axial, (b) T2 coronal, (c) T1 sagittal and, (d) MR angiogram sequence of cerebral magnetic resonance imaging reveals a left frontal well defined flow void of size 60 x 66 mm communicating with the superior sagittal sinus through dilated cortical vein with feeder supply from left anterior cerebral artery
case_images: SNI-4-22-g002.jpg
case_images: PMC3604817_01_SNI-4-22-g002.jpg
case_images: F2
case_images: A left frontal well defined flow void of size 60 x 66 mm communicating with the superior sagittal sinus (SSS) through dilated cortical vein with feeder supply from left ACA was observed in the cranial magnetic resonance imaging (MRI) with angiogram [Figure 2].
case_images: 128 Multi slice cerebral computed tomographic angiography sagittal (a) and coronal (b) view demonstrates a large left frontal arteriovenous fistula supplied by the distal left anterior cerebral artery draining through a dilated cortical vein into the superior sagittal sinus. A large variceal dilatation of the proximal venous end measuring nearly 6.5 cm in diameter with wall calcification is shown in association with the arteriovenous fistula
case_images: SNI-4-22-g003.jpg
case_images: PMC3604817_01_SNI-4-22-g003.jpg
case_images: F3
case_images: AVF with large venous varix was considered. 128 Multi slice cerebral CT angiography (CTA) revealed a large left frontal AVF supplied by the distal left ACA draining through a dilated cortical vein into the SSS [Figure 3]. A large variceal dilatation of the proximal venous end measuring nearly 6.5 cm in diameter with wall calcification was noted in association with the AVF.
case_images: Intraoperative photograph showing the large venus varix (a and b) with cut open gross section of the variceal sac (c) after excision
case_images: SNI-4-22-g004.jpg
case_images: PMC3604817_01_SNI-4-22-g004.jpg
case_images: F4
case_images: On reflecting the dura to opposite side, a globular soft pinkish pulsatile varix (  6 x 6 cm) was encountered superficially in left frontal lobe [Figure 4a and b] close to the anterior falx with dilated draining vein reaching up to the anterior part of the SSS. Hence total excision of the AVF mass along with the venous varix was performed [Figure 4c] after ligating the primary feeding artery.
case_images: Postoperative contrast enhancing cerebral computed tomographic axial (a) and sagittal, (b) picture demonstrates a large filling defect in the area of the varix excision. Computed tomographic angiography (c and d) shows complete obliteration of the arteriovenous fistulas and reconstitution of the distal anterior cerebral artery
case_images: SNI-4-22-g005.jpg
case_images: PMC3604817_01_SNI-4-22-g005.jpg
case_images: F5
case_images: A CT scan on second postoperative day demonstrated a large filling defect in the area of the varix excision [Figure 5a and b]. Postoperative CTA done at the time of discharge showed complete obliteration of the AVF and reconstitution of the distal ACA [Figure 5c and d].