Intracranial Pial Arteriovenous Fistula Presenting with Hemorrhage: A Case Report
A 15-year-old girl with an altered mental state was transferred to our hospital. She complained of headache and vomiting before her arrival, and her mental state showed an immediate decrease. Findings on the initial neurological examination indicated that she was in a stupor state (Glasgow Coma Scale was E3 V4 M5). She had no history of head trauma. Computed tomography (CT) performed for evaluation of the cause of her altered mental state showed a subcortical hematoma of approximately 24 in her right temporal lobe. CT angiogram performed in order to evaluate the cause of the hemorrhage identified a suspicious abnormal vessel around the hematoma (). Magnetic resonance imaging (MRI) and cerebral angiography were performed for further evaluation of vascular malformation and to search for other causes of the hemorrhage. No nidus or mass lesion was observed in the enhanced MRI image (). Cerebral angiography identified a possible AVF. The AVF was supplied by the right middle cerebral artery (MCA) and drained into the Sylvian vein and the vein of Labbe in the early venous phase ().\nA right frontotemporal craniotomy and Sylvian arachnoid dissection were performed, and an AVF consisting of the feeding artery and draining vein shown in the preoperative angiography was exposed (). A flow similar to arterial pulsation in the draining vein was observed on Doppler ultrasonography for assessment of vessel flow. The feeding artery was closed by application of a clip; however, arterial pulsation remained in the draining vein. The dissection and removal hematoma were extended, and other small feeding arteries were observed at the base of the hematoma. Arterial pulsation in the draining vein disappeared after obliteration of the arteries by cauterization. Cerebral angiography performed one week postoperatively showed the disappearance of the early draining venous flow through the Sylvian vein and the vein of Labbe, indicating complete obliteration of the fistula (). The patient was discharged one week later without neurologic deficit.