The authors report a case of dural arteriovenous fistula in the anterior fossa that presented with impending herniation due to right frontal intracerebral and subdural hematoma. The patient, a 67-year-old male, suffered from a sudden headache and lapsed into a coma. CT scan, 2 hours after onset, showed a right frontal intracerebral, thick subdural hematoma. He was comatose, and his right pupil was fully dilated with no light reflex. Under local anesthesia and drip infusion of mannitol, emergent one burr hole drainage for subdural hematoma was performed as soon as possible after admission. This emergent procedure dissolved the impending herniation. Thereafter, under general anesthesia, intraoperative digital subtraction angiography was performed using a portable digital subtraction angiography (DSA) system. A dural arteriorvenous fistula in the anterior fossa was disclosed by DSA. Removal of the subdural hematoma and varix of the dural arteriovenous fistula was completed in one session. About seven weeks later, he was able to return to home without neurological deficit. Emergent one burr hole craniotomy was useful for avoiding impending cerebral herniation due to acute subdural hematoma. Intra-operative DSA was also useful for diagnosing an unknown cause of hemorrhage before radical removal of the subdural hematoma.
