PMC10069915_01
Clinical course of the patient's chronic subdural hematoma.
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A. A left chronic subdural hematoma was detected on magnetic resonance imaging during a medical check-up.
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B. Computed tomography on postoperative day 1 after the first burr hole surgery for the left chronic subdural hematoma, which was performed one month after the first magnetic resonance imaging examination.
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C. Computed tomography revealed the recurrence of the left chronic subdural hematoma one month after the first burr hole surgery.
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D. Computed tomography on postoperative day 1 after the second burr hole surgery for the left chronic subdural hematoma.
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An 81-year-old man without a specific history of head trauma was incidentally diagnosed with asymptomatic left CSDH (Fig. 1A) and conservatively observed. However, his CSDH increased in size with mild right hemiparesis one month later, and he underwent burr hole irrigation and drainage for the left CSDH (Fig. 1B). However, he experienced mild right hemiparesis again one month after the initial surgery, and computed tomography (CT) revealed recurrence of the left CSDH (Fig. 1C). The patient underwent second burr hole irrigation and drainage procedure (Fig. 1D).
Cerebral angiography and middle meningeal artery embolization.
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A. Anteroposterior view of the left external carotid artery angiography revealed a left convexity dural arteriovenous fistula. The feeders were the anterior convexity branches of the middle meningeal artery (white arrow) and drainers were the sylvian veins (white arrowhead).
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B. Lateral view of the left external carotid artery angiography showed a faint stain at the shunt point of the dural arteriovenous fistula (black arrow).
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C. Lateral view of selective angiography of the left middle meningeal artery during middle meningeal artery embolization.
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D. Lateral view of the left external carotid artery angiography demonstrated that the dural arteriovenous fistula was occluded.
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The feeders of the DAVF were the anterior convexity branches of the MMA, and the drainers were the sylvian veins (Fig. 2A). Furthermore, cerebral angiography revealed faint staining at the shunt point of the DAVF (Fig. 2B). The shunt point of the DAVF was adequately occluded (Fig. 2C, D).
Chronological changes in cerebral imaging.
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A. The dural arteriovenous fistula (white arrow) was retrospectively confirmed on a magnetic resonance imaging examination performed during a medical check-up five years before the appearance of the chronic subdural hematoma.
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B. A follow-up computed tomography at five months post-embolization showed complete disappearance of the chronic subdural hematoma. The embolization material, N-butyl2cyanoacrylate, had well penetrated to the shunt point of the dural arteriovenous fistula (white arrow).
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The patient's past magnetic resonance imaging findings after embolization was retrospectively reviewed, and DAVF was confirmed in the image obtained five years before the appearance of CSDH (Fig. 3A). A follow-up CT examination at five months post-embolization showed complete disappearance of both the DAVF and CSDH, and the patient remained symptom-free (Fig. 3B).
Fusion three-dimensional computer graphics integrating magnetic resonance imaging and three-dimensional rotational angiography.
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A. Fusion three-dimensional computer graphics image showing that the shunt point of the dural arteriovenous fistula (red arrow) was far from the burr hole (red arrowhead).
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B. Fusion three-dimensional computer graphics image showing that the shunt point of the dural arteriovenous fistula was in contact with the outer membrane of chronic subdural hematoma membrane (red arrow).
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Fusion three-dimensional computer graphics images were reconstructed using GRID 1.1 software (Kompath Inc., Tokyo, Japan).
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This application provides automatic image registration for multiple imaging studies using normalized mutual information.) The 3DCG examinations revealed that the shunt point of the DAVF was far from the burr hole (Fig. 4A); moreover, it was in contact with the outer membrane of CSDH (Fig. 4B). The DAVF was almost at the center of the CSDH; however, there was no hematoma at the shunt point.