Arteriovenous malformation presenting as traumatic subdural hematoma: A case report

Abstract

Background: Brain arteriovenous malformations (AVMs) are congenital aberrant connections between afferent arteries and draining veins with no intervening capillary bed or neural parenchyma. Other than seizures, the most common initial presentation of AVM is hemorrhage, which is typically intraparenchymal, subarachnoid, or intraventricular, and very rarely subdural.

Case description: This patient is a 66-year-old male with a history of atrial fibrillation, chronically anticoagulated with apixaban, who presented through emergency services after a fall. On presentation, computed tomography (CT) of the head showed a small, 6 mm right subdural hematoma, and the patient was neurologically intact. The hematoma was evacuated by burr hole craniotomy and placement of a subdural drain 12 days after the initial presentation due to worsening headaches and further hematoma expansion. Two weeks postevacuation, the patient was readmitted for seizures, and at this time, CT angiography showed no intracranial vascular lesion. Approximately 1 month later, the patient was readmitted for decreased responsiveness, and CT head at this time found right frontal intraparenchymal hemorrhage. On subsequent catheter angiography, the right frontal AVM was discovered. It was treated with preoperative embolization followed by surgical resection. Postoperatively, the patient followed commands and tracked with his eyes. There was spontaneous antigravity movement of the right upper extremity, but still no movement of the left upper or bilateral lower extremities.

Conclusion: This case emphasizes the importance of maintaining a high index of suspicion for underlying vascular lesions when evaluating intracranial bleeding, even in the setting of traumatic history, particularly in cases of hematoma expansion.

Keywords: Arteriovenous malformation; Intracranial hemorrhage; Subdural hematoma.

Figure 1:

(a) Noncontrast computed tomography (CT) head on initial presentation to emergency department, demonstrating small right subdural hematoma. (b) Noncontrast CT head on hospital day 2 demonstrating expansion of the right subdural hematoma.

Figure 2:

(a) Noncontrast computed tomography (CT) head on representation for headache. Expansion of hematoma to 15 mm with 8 mm midline shift. (b) Noncontrast CT head after burr hole craniotomy to evacuate subdural hematoma, showing improvement in mass effect and midline shift.

Figure 3:

Noncontrast computed tomography head showing 5.2 cm×3.3 cm intraparenchymal hemorrhage

Figure 4:

(a and b) Cerebral angiogram showing early filling of draining vein of arteriovenous malformations (AVM). (c and d) Postembolization cerebral angiogram with no filling of draining vein of AVM.