- Department of Neurosurgery, Stanford University School of Medicine, Stanford, United States.
Michael Zhang Department of Neurosurgery, Stanford University School of Medicine, Stanford, United States.
DOI:10.25259/SNI_671_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Michael Zhang1, Parastou Fatemi1, Jamshid Ghajar1. Acquired dural arteriovenous fistula after subdural evacuation port system placement: A case report. 18-Nov-2022;13:540
How to cite this URL: Michael Zhang1, Parastou Fatemi1, Jamshid Ghajar1. Acquired dural arteriovenous fistula after subdural evacuation port system placement: A case report. 18-Nov-2022;13:540. Available from: https://surgicalneurologyint.com/surgicalint-articles/12006/
Background: The subdural evacuation port system (SEPS) is a rapid, bedside, and less invasive option for subdural hemorrhage management. Proper procedure planning and understanding of the relevant vascular anatomy is important for minimizing complications and future procedures.
Case Description: We describe a case where following placement of a SEPS, there was immediate development of a new dural arteriovenous fistula (dAVF) between the middle meningeal artery (MMA) and middle meningeal vein. Angiography confirmed site of shunting to be at the proximity of the twist drill hole placement. Subsequent MMA embolization was performed and follow-up MRI confirmed resolution of the dAVF.
Conclusion: SEPS-associated dAVF is an underreported complication with potential long-term consequences. This case describes the complication and advocates avoiding SEPS anterior to the coronal suture.
Keywords: Case report, Dural arteriovenous fistula, Middle meningeal, Subdural hemorrhage
Dural arteriovenous fistula (dAVF) is an extracranial arterial blood flow shunt within the leaflets of the dura mater.[
Here, we present the first reporting of a dAVF following subdural evacuation port system (SEPS) placement for the evacuation of a subdural hematoma (SDH). Patient consent was obtained. The case provides insight into the possible development timeline of an acquired dAVF. Moreover, this case report offers anatomic guidance on the surgical planning of SEPS for hematoma management and relevant postoperative treatment for postsurgical dAVF.
A 93-year-old female on apixaban for atrial fibrillation presented after a ground level fall with difficulty speaking and an otherwise intact neurological examination. Her head computed tomography (CT) was trended until stable and identified a 16 mm SDH with 9 mm midline shift (MLS; [
Coronal computed tomography (CT) head imaging of the patient at (a) initial presentation and (b) 2-week follow-up, after discharge from her subdural evacuation and middle meningeal embolization. Initial presentation demonstrated a 15 mm midline shift. Final follow-up CT described a 3 mm midline shift.
She had a frontal SEPS drainage placement and a postprocedural CT head showed interval decrease in the SDH to 1.7 cm with an 11 mm MLS [
Dual subtraction angiography of the left external carotid from (a) lateral and (b) anterior-posterior views following SEPS drainage demonstrating the anterior left middle meningeal artery supplying a postsurgical arteriovenous fistula with drainage into the left middle meningeal vein, without cortical venous drainage.
A week later, she was at her normal neurological baseline. After additional monitoring, she was ultimately discharged with recommendations to hold anticoagulation for 6 weeks. At 2-week follow-up, a repeat CT head scan identified further reduction in the SDH, measuring 1.5 cm with a 3 mm MLS.
Iatrogenic dural arteriovenous fistula have been associated with surgical interventions, but primarily intracranial procedures.[
Similar traumatic MMA-MMV dAVF have been described and have radiographically been characterized to have a “tram-track” presentation.[
Two case reports of ventriculostomy associated dAVF have been described; however, both were associated with aneurysmal subarachnoid hemorrhage.[
This case also demonstrates the possible significance of SEPS site selection. The coronal suture is an important landmark as the MMA trajectory runs posterior to it.[
Dural injury with a twist drill can lead to formation of a dural arteriovenous fistula within the same day of the associated dural trauma. Surgical planning should incorporate the underlying arterial and venous anatomy to reduce the need for subsequent follow-up and treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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