Giant dural arteriovenous fistula in an infant
A one-month-old female presented with irritability and failure to thrive. She was the product of a 35-week pregnancy and was delivered vaginally without complications or a difficult labor. Prenatal ultrasonography was not performed. Her Apgar score was 7. The parents reported failure to thrive and an infant who was minimally responsive although she would open her eyes and was able to follow objects. Her pupils were more or less symmetrical. Blood chemistry panels were within normal limits. On physical exam, the infant moved all extremities to stimulation and grimaced to pinch. The anterior fontanelle was full and tense and the head circumference was 42 cm. The sutures of the calvaria were split. There was an upgaze palsy. Reflexes were found to be hypotonic. No cutaneous stigmata were identified.\nA subsequent magnetic resonance imaging (MRI) identified a large, somewhat spherical mass with significant flow void filling most of the posterior cranial fossa and extending superiorly to the underside of the calvaria (). In total, the mass filled approximately one half of the intracranial volume. No cerebellum was identified and the brainstem was significantly compressed against the clivus (). Hydrocephalus was present, especially involving the temporal horns (). The internal jugular veins were dilated () and the circle of Willis and vertebrobasilar vessels appeared normal () although the resolution of the imaging was poor primarily due to the age of the patient, therefore, based on the findings of MRI, the diagnosis of a giant dAVF involving the transverse-sigmoid sinuses was made. The patient was scheduled for an arteriogram but died before the procedure could be performed.