Intracranial dural fistula: case report (Atena Editora)

Abstract

Case Presentation: Male patient, 40 years old, admitted to the hospital unit with progressive headache for 1 week, in weight, holocranial, associated with bilateral pulsatile tinnitus, without changes suggestive of ICH. He progressed with generalized tonic-clonic seizures, followed by sphincter release and loss of consciousness in July/2021, and was transferred to the hospital. He required orotracheal intubation and was diagnosed with ASH in the frontal region, right temporal region, and near the right sylvinian fissure by CT and Angio-CT, and failure to fill the sagittal venous sinus after contrast administration. Patient showed clinical improvement, with subsequent hospital discharge and recommendation for outpatient arteriography due to idiopathic HSA. Differential diagnosis was made with cerebral venous thrombosis or intracranial dural fistula. A new arteriography demonstrated the presence of a dural arteriovenous fistula in the left transverse/sigmoid venous sinus, Cognard grade 1, with absence of venous reflux; associated with partial venous thrombosis of the superior sagittal sinus and of the left transverse/sigmoid sinus. Discussion: Intracranial dural fistulas represent 15% of intracranial vascular malformations, occurring frequently in patients between 50 and 60 years of age. Usually acquired, they may present in a silent or diverse symptomatic manner, ranging from less aggressive manifestations, such as headache and tinnitus, to more aggressive ones, such as progressive cognitive decline, determined by both the venous drainage pattern and the location of the fistula. These fistulas can occur in any portion of the intracranial dura, primarily the cavernous sinus, transverse sigmoid sinus, and the cerebral tent. CT, Angio-CT and MRI are the first-line diagnostic tools. However, digital subtraction angiography has established itself as the gold standard to detect, evaluate and follow up on a suspected intracranial dural fistula. In the case, the established relationship between dural fistula with thrombosis and the possibility of hemorrhagic transformation in the face of this obscures the cause-consequence relationship. The therapeutic options for the fistulas in question involve conservative, endovascular or surgical treatment, with endovascular being the most indicated, due to the low rate of complications.