Coexistence of three dural arteriovenous fistulas in the anterior cranial fossa, petrous ridge and superior sagittal sinus: A case report.

Introduction And Importance: The coexistence of three dural arteriovenous fistulas (DAVFs) in the anterior cranial fossa (ACF), petrous ridge and superior sagittal sinus (SSS) is rare. Such a complex and rare case can be managed with endovascular treatment (EVT).

Case Presentation: A 74-year-old male with an intracranial hemorrhage was admitted in a comatose state. His Hunt-Hess scale - was grade III. Computed tomography (CT) revealed frontal lobe hemorrhage into lateral ventricle. Digital subtraction angiography (DSA) revealed the coexistence of three DAVFs in the ACF, left petrous ridge and right SSS. The ruptured DAVF in the ACF was embolized via the ophthalmic artery with the assistance of the "pressure cooker" technique. Then, the DAVF in the petrous ridge was embolized via the middle meningeal artery. The DAVF in the SSS was not managed due to low Cognard classification. Burr hole drainage of the frontal lobe hematoma and intraventricular hemorrhage was performed immediately after EVT. The patient gradually recovered after treatment. At the 2-week follow-up, the patient could answer simple questions, and his upper and lower limbs had grade V muscle strength. CT revealed that the intracranial hemorrhage had been absorbed. During the 3-month follow-up, the patient reported that he could take care of himself.

Clinical Discussion: When ACF DAVF was involved in multiple DAVFs, it was often symptomatic and ruptured. Burr hole drainage may be necessary when intracranial hemorrhage was serious.

Conclusion: In multiple DAVF, those with high Cognard classification should receive aggressive treatment. EVT may be an option.