case_images: PMC10757922_01
case_images: (A) Admission axial CT scan, indicating multiple scattered hemorrhagic foci in both cerebral hemispheres (white arrowheads). (B) Preoperative axial CT scan showing the progression of hemorrhage in the left frontal lobe (white arrowheads).
case_images: fneur-14-1303234-g001.jpg
case_images: PMC10757922_01_fneur-14-1303234-g001.jpg
case_images: fig1
case_images: Ophthalmological examination revealed papilledema (Figure 1, Supplementary material). Upon further examination, it was observed that the cerebral hemorrhage had significantly intensified compared to the time of admission (Figure 1).
case_images: (A) Anteroposterior view of the left common carotid artery angiography venous phase before endovascular surgery, a congenital absence of the left transverse sinus is shown (white solid line) and severe varix of bilateral cortical veins (white dashed circles). In the lateral view of the left common carotid artery angiography, (B,C) demonstrating an arteriovenous shunt (white arrowheads). The arteriovenous shunt is fed by the left occipital artery (white arrow), left MMA occipital branch (white arrow), and drains into SSS (black arrow) around the torcular area. (D) Superselective angiography of the left occipital artery and MMA branch obtained before ONYX glue injection, demonstrating multiple arterial channels flowing into the fistula. (E) Intraoperative angiography obtained after ONYX injection shows a cast of glue occluding the fistula, including all the left feeding arteries and part of the compensatory veins (black dashed circle), with increased cortical vein varix (white dashed circle).
case_images: fneur-14-1303234-g002.jpg
case_images: PMC10757922_01_fneur-14-1303234-g002.jpg
case_images: fig2
case_images: After several attempts, the final angiography showed no branches supplying the fistula from the left internal and external carotid arteries, but a small amount of supply from the right OA remained, suggesting a slight residual shunt (Figure 2).
case_images: (A) Post-embolization axial and sagittal CT scans show a high-density area, demonstrating a cast of glue occluding the fistula (black dashed circle), including feeding arteries and the SSS (white arrow). (B) Postoperative follow-up CT revealed hemorrhage in the left frontal lobe, posterior temporal region, and right temporal lobe. Discharge review showed that the hematoma had been essentially absorbed (white arrowhead). (C) Postoperative follow-up MRV images in oblique posterior and posterior views revealed well-developed bilateral Labbe veins (white arrowheads), a variation in the left transverse sinus (white dashed line), and the presence of thrombosis in the SSS (white arrow). (D) DSA 3-month follow-up compared to post-surgery shows a significant reduction in cortical venous varix (left), with the fistula completely occluded and no recurrence.
case_images: fneur-14-1303234-g003.jpg
case_images: PMC10757922_01_fneur-14-1303234-g003.jpg
case_images: fig3
case_images: A one-year postoperative MR review indicated no recurrence of dAVF, although thrombosis was observed in the SSS (Figure 3), the patient's condition and vision improved, with no significant neurological abnormalities.