Multiple intracranial dural arteriovenous fistula
A fifty year old man with history of long term headache and sudden onset of decreased level of consciousness was admitted to Namazee Hospital, affiliated to Shiraz University of Medical Sciences, Shiraz, Iran, in 2011. Brain computed tomography (CT) showed right parietal intraparenchymal hemorrhage []. The patient had glasgow coma scale (GCS) 12 on arrival.\nBrain magnetic resonance imaging (MRI) with and without gadolinium was performed to rule out tumor apoplexy that showed two round right parieto-occipital masses with flow void intensity adjacent to superior sagittal sinus (SSS) []. Brain CT angiography (CTA) revealed a mass of 3 × 2 × 2 cm connected to SSS in posterior part of right parieto-occipital area. Another pathology connected to SSS by an abnormal cortical vein was detected anterior to first lesion []. Digital subtraction angiography of brain vessels showed large vascular pathology that filled at early arterial phase by a torturous extra cranial vessel and drained into the posterior third of SSS. More anterior lesion was smaller vascular pathology that supplied at early arterial phase by posterior branch of middle meningeal artery and drained into SSS by an abnormal cortical vein that classified according to Borden classification type II [].[]\nRegarding the patient's history and images, DAVF was diagnosed. Because of the site of his pathologies, multiplicity and difficulty of endovascular treatment, open craniotomy was suggested for removal.\nGeneral anesthesia was administered in prone position and the face rotated to the left side. In this position right parieto-occipital area was in highest part. Then a large right parieto-occipital craniotomy with excellent exposure of SSS was performed. When the bone was elevated, bleeding occurred. Source of bleeding was from two dilated meningeal arteries that was controlled easily. Dura was opened and the two large masses with separate arterial and venous structure were found. The larger pathology had a large vascular pedicle that had connection to SSS and dural vessels and was ligated []. After preparation of the site for applying emergency temporary clip, the thick wall mass that was free of pulse was dissected carefully. When the lesion was removed from parenchyma, a permanent titanium yasargil clip was applied on its vascular pedicle and the lesion was resected totally without parenchymal damage. The anterior pathology was removed in the same manner. Abnormal cortical vein was also resected. Hemostasis was carried out and dura was closed.\nPostoperative brain CT-scan of the patient was acceptable and there was no vascular pathology in the brain CTA. No neurological deficit was found. The patient was discharged from the hospital with GCS 14.