Fatal progression of posttraumatic dural arteriovenous fistulas refractoryto multimodal therapy - Case report

The authors report the case of a man who suffered from progressive, dissemi nated posttraumatic dural arteriovenous fistulas (DAVFs) resulting in death , despite aggressive endovascular, surgical, and radiosurgical treatment. This 31-year-old man was struck on the head while playing basketball. Two w eeks later a soft, pulsatile mass developed at his vertex, and the man bega n to experience pulsatile tinnitus and progressive headaches. Magnetic reso nance imaging and subsequent angiography revealed multiple AVFs in the scal p, calvaria, and dura, with drainage into the superior sagittal sinus. The patient was treated initially with transarterial embolization in five stage s, followed by vertex craniotomy and surgical resection of the AVFs. Howeve r, multiple additional DAVFs developed over the bilateral convexities, the fair, and the tentorium. Subsequent treatment entailed 15 stages of transar terial ernbolization; seven stages of transvenous embolization, including c omplete occlusion of the sagittal sinus and partial occlusion of the straig ht sinus; three stages of stereotactic radiosurgery; and a second craniotom y with aggressive disconnection of the DAVFs. Unfortunately, the fistulas c ontinued to progress, resulting in diffuse venous hypertension, multiple in tracerebral hemorrhages in both hemispheres, and, ultimately, death nearly 5 years after the initial trauma. Endovascular, surgical, and radiosurgical treatments are successful in curi ng most patients with DAVFs. The failure of multimodal therapy and the fulm inant progression and disseminated nature of this patient's disease are uni que.