Serial angiography of dynamic changes of traumatic middle meningeal arteriovenous fistula - Case report

A 48-year-old woman suffered head trauma and presented with an acute epidural hematoma with a linear fracture of the right temporal bone across the middle meningeal groove. Initial angiography demonstrated no vascular abnormalities. Eight months later, she again suffered head trauma and computed tomography demonstrated traumatic subarachnoid hemorrhage. Right external carotid angiography revealed a middle meningeal arteriovenous fistula (AVF) which drained into the superficial sylvian veins via the sphenoparietal sinus. Serial angiography showed progressive dilation of the draining veins, but she refused surgical intervention and dropped out of our outpatient clinic. Fifteen years after the first head trauma, she presented with subarachnoid hemorrhage. Angiography demonstrated formation of venous aneurysms on the drainer of the AVF. The dilated superficial sylvian vein was removed together with the ruptured venous aneurysm. Histological examination of the drainer revealed an arterialized vein. The serial angiographic evaluations revealed dynamic changes of the traumatic middle meningeal AVF, including progressive dilation of the drainers, simplification of the drainage routes, and the formation of venous aneurysms, which presumably represents the entire natural course of traumatic middle meningeal AVF manifesting as hemorrhage. The present case of traumatic middle meningeal AVF with a deteriorating course suggests that surgical removal or embolization of the AVF is strongly indicated if follow-up angiography shows dilation of the drainers, which implies increased shunt flow.