PMC10370508_01
(A) A CT at admission showing an intracerebral hemorrhage in the temporo-occipital cortex (arrow). (B) An MRA showing an anomalous vessel structure around the Sylvian fissure area (arrow).
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F1
A CT scan showed a hematoma in the right temporo-occipital cortex (Fig. 1A). An MRA revealed an anomalous vessel structure in the region of the right Sylvian fissure (Fig. 1B).
(A) The right ECA angiogram (lateral view) showing an AV shunt (arrow). (B) A 3D DSA with a skull image demonstrating the feeding arteries, which are the deep temporal artery (red, arrowhead), the middle meningeal artery (MMA) (red, arrow), and the anterior auricular branch of the superficial temporal artery (yellow). These merge into the shunt point (yellow arrow) and drain into the SMCV. The deep temporal artery and the anterior auricular branch go from the subcutaneous layer into the intracranial space through the bone edge at the skull base side. (C) The right MMA selective angiogram (frontal view) showing an AV shunt (arrow). (D) The MMA angiogram (lateral view) showing an AV shunt (arrow). The collected feeders are shunting directly into the SMCV. (E) The late arterial phase of the right external carotid angiogram (lateral view) showing the arterial blood flow into the SMCV (arrow) and reflux into the cortical veins. (F) A fluoroscopy showing penetration of NBCA into the shunt point including the venous outlet (arrow). A microcatheter was placed in proximity to the shunt point through a loosely packed coil (arrowhead). (G) A right external carotid angiogram after the embolization demonstrating the complete disappearance of the dural artery-pial vein shunt. AV: arteriovenous; ECA: external carotid artery; MMA: middle meningeal artery; NBCA: n-butyl-2-cyanoacrylate; SMCV: superficial middle cerebral vein
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F2
The right external carotid artery (ECA) angiogram showed a dural artery-pial vein shunt in proximity to the previous craniotomy center, supplied by the anterior deep temporal artery (ADTA), the middle meningeal artery (MMA), and the anterior auricular branch of the superficial temporal artery (Fig. 2A). On the 3D DSA images superimposed to the skull image, both the ADTA and the anterior auricular artery could be seen entering the intracranial space through the bone edge of the craniotomy site at the temporal base and running on the dural surface to the shunt point (Fig. 2B). The right MMA selective angiogram showed that the feeder arteries were combined and flowed directly into the superficial middle cerebral vein (SMCV) (Fig. 2C and 2D). The connection between the SMCV and the cavernous sinus was occluded, and the venous drainage refluxed through the cortical veins into the basal vein of Rosenthal and the superficial cortical veins in the parietal area (Fig. 2E). The shunt point and venous outlets were occluded using 33% NBCA (Fig. 2F). The shunt completely disappeared on the final cerebral angiogram (Fig. 2G).
(A) A 3D DSA showing the shunt feeders: the anterior auricular branch of the superficial temporal artery (white arrowheads) is flowing directly into the SMCV (thin white arrows), and the MMA (yellow arrowheads) is also flowing directly into the SMCV (thin white arrows). The white and yellow thick arrows indicate the respective shunt points. (B) The coronal image of the right ECA MIP showing feeders from the anterior auricular branch (white arrowheads). (C) The right ECA MIP coronal image showing the AV shunt point of the feeders from the anterior auricular branch (white arrow) and feeders from the MMA (yellow arrow) on the SMCV. (D) The right ECA MIP coronal image showing the SMCV (thin white arrows) and shunt point of the feeders from the MMA (yellow arrow) on the SMCV. AV: arteriovenous; ECA: external carotid artery; MIP: maximum intensity projection; MMA: middle meningeal artery; SMCV: superficial middle cerebral vein
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F3
The right ECA maximum intensity projection (MIP) coronal image showed that the collected feeders from the anterior auricular branch shunted directly into the SMCV (Fig. 3A-3C).