Iatrogenic traumatic superficial temporal arteriovenous fistula development post-craniectomy: A case report

Abstract

We report a case of superficial temporal arteriovenous fistula development following frontotemporoparietal hemicraniectomy. This patient presented with intracerebral hemorrhage (ICH) secondary to underlying arteriovenous malformation (AVM) rupture. Following decompressive hemicraniectomy and follow-up successful resection of the underlying AVM, the patient returned to the hospital with a seizure. Repeat angiography was performed, demonstrating no intracranial vascular lesion recurrence. However, an incidental superficial temporal arteriovenous fistula was identified, which was not visualized on initial angiography assessing the prior AVM. These lesions have been treated successfully in the past with surgical, endovascular, or combined approaches. As this patient was scheduled to undergo cranioplasty following AVM resection, the decision to occlude the fistula surgically was made. During cranioplasty, the fistula was identified as an engorged venous complex contiguous with the superficial temporal artery (STA) and was occluded. Follow-up angiography confirmed successful fistula occlusion and the patient has remained asymptomatic.

Keywords: Temporal artery; craniotomy; fistula; postoperative complications.

Figure 1.

Presenting ICH, AVM with pseudoaneurysm, and successful AVM resection. (a/b) Axial view CTA performed on presentation to MGH. Large isodense ICH in left frontoparietal region with underlying AVM (arrow) and superficial draining venous anatomy (arrow). (c) Lateral view left ICA angiography following decompressive hemicraniectomy. Pseudoaneurysm development (arrow) is visualized contiguous with the AVM (arrow), along with superficial venous drainage (arrow). (d) Lateral view left ICA angiography showing angiographic cure following obliteration of pseudoaneurysm and AVM. Abbreviations: ICH—intracerebral hematoma, AVM—arteriovenous malformation, CTA—computed tomography angiography, MGH—Massachusetts General Hospital, ICA—internal carotid artery.

Figure 2.

CTA MIP demonstrates crossing of STA and STV, angiography demonstrates STA fistula (a) Lateral view CTA MIP preceding development of STA fistula. The STA can be seen crossing superficial to the underlying STV in the region of the subsequent fistula development. (b/c/d) Lateral view left ECA angiography following AVM resection. Retrograde venous filling of the STV is visualized as angiography progresses from panel B through D, underscoring STA fistula development Abbreviations: CTA—computed tomography angiography, MIP—maximum intensity projection, STA—superficial temporal artery, STV—superficial temporal vein, ECA—external carotid artery, AVM—arteriovenous malformation.