A case of intracranial hemorrhage due to rupture of aneurysm of the distal posterior cerebral artery associated with dural arteriovenous fistulas of the falcine sinus

Abstract

Objective: This report describes a rare case of a dural arteriovenous fistula of the falcine sinus associated with a flow-related aneurysm.

Patient and methods: A 68-year-old man presented with severe headache secondary to an intracranial hemorrhage. The bleeding was caused by a dural arteriovenous fistula (dAVF) of the falcine sinus with a flow-related aneurysm of the dural branch of the right posterior cerebral artery.

Results: Trans arterial obliteration of the aneurysm and its feeder using glue and trans venous embolization of the draining portions using a coil were successfully performed.

Conclusion: The unusual coexistence of a flow-related aneurysm on the feeder of the dAVF resulted in a unique hemorrhage.

Keywords: dural arteriovenous fistula; falcine sinus; flow-related aneurysm.

Figure 1

(A) Axial and (B) sagittal computed tomography of the brain show the right occipital lobe hemorrhage with ventricular perforation. (C) Merged figure of magnetic resonance image and the axial view of computed tomography angiography. The aneurysm is located at the edge of the hematoma. It is indicated by the white arrow. (D) Three-dimensional angiography shows the aneurysm at the pial branch of the right posterior cerebral artery.

Figure 2

Three-dimensional cerebral angiography of both common carotid arteries are merged. (A) Anterior-posterior and (B) posterior-anterior views describe the arterial-venous shunt. (C) Magnetic resonance angiography shows the shunt from the right posterior cerebral artery to the vein of Galen. Feeder arteries are the bilateral middle meningeal arteries, occipital arteries and meningeal brunch of the right posterior cerebral artery shunt to the falcine sinus and vein of Galen. Shunt points are indicated by white arrows. Anterograde flow toward the straight sinus is observed. (D) Anterior-posterior and (E) lateral views of right internal carotid artery angiography. The arrowhead shows the aneurysm of the right posterior cerebral artery. (F, G) The micro angiography of the pial branch of the right posterior cerebral artery associated with the aneurysm shows the direct arterial-venous shunt to the sinus system at the peripheral end. The aneurysm is indicated by the arrowhead. The draining sinus is indicated by the arrows.

Figure 3

(A, E) Cranial x-ray and (B, F) angiography of the right common carotid artery after the (A, B) first and (E, F) second embolization are shown. At the first time, (A) the peripheral part of the falcine sinus is packed with the coil and (B) the outflow to the straight sinus and the vein of Galen is preserved. Left vertebral artery angiography (C) before and (D) after embolization of the aneurysm and the parent artery. The right P3 segment of the posterior cerebral artery is occluded with 20% n-butyl-2-cyanoacrylate. The arrowhead indicates right P3 trajectory. The arrow indicates the aneurysm. After the second embolization, (E) the falcine sinus, vein of Galen and straight sinus are packed, and (F) the shunt flows has disappeared.