Segmental microbleeds: a radiological sign for cranial dural arteriovenous fistula

Abstract

A 57-year-old man presented to the emergency department following a road traffic accident, having experienced a sudden ascending 'wave of emotion'. After the event, he developed an intense right-sided temporal headache and was thought to have a complex grief reaction resulting from a recent bereavement. Given persistent symptoms, a computed tomography (CT) scan of head was conducted at an outpatient transient ischaemic attack (TIA) clinic, which showed a possible right occipital infarct. Further magnetic resonance imaging (MRI) scanning revealed instead a segmental area of microbleeds in the posterior right temporal lobe, with occipital extension. Upon discussion at the neuroradiology multidisciplinary team meeting and subsequent digital subtraction angiography (DSA), a cranial dural arteriovenous fistula (DAVF) was confirmed. He underwent a successful embolisation, with his symptoms fully resolving 16 months later.

Keywords: digital subtraction angiography; dural arteriovenous fistula; microbleed.

Fig 1.

Computed tomography scan of brain showing low attenuation (arrow) at the right parieto-occipital lobe.

Fig 2.

Magnetic resonance imaging of brain (gradient echo sequence) showing a segmental area of microbleeds (blue arrows) affecting the right temporal lobe posteriorly and extending toward the occiput.

Fig 3.

Digital subtraction angiography. (a) Right posterior temporal dural arteriovenous fistula (blue arrows). (b) Congested cortical veins. ECA = echo contrast agent.