Delayed Intracerebral Hemorrhage Following Transarterial Embolization for a Tentorial Dural Arteriovenous Fistula: Postoperative Venous Outflow Impairment Detected by Susceptibility-Weighted Imaging

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Objective: We report a rare case of delayed intracerebral hemorrhage that was possibly related to venous outflow impairment after transarterial embolization (TAE) with Onyx (Medtronic, Dublin, Ireland) for a tentorial dural arteriovenous fistula (DAVF). We also discuss the potential role of susceptibility-weighted imaging (SWI) in the early detection of postoperative venous circulatory disturbance.

Case Presentation: A 65-year-old man with a history of atherosclerotic stroke was diagnosed with a left tentorial DAVF (Borden type III, Cognard type IV). TAE with Onyx was performed, and complete obliteration of the shunt was achieved. MRI obtained 1 day after embolization revealed FLAIR hyperintensity near the shunt point and hypointense signals on SWI, suggesting venous outflow impairment. On postoperative day 6, the patient developed a large subcortical hemorrhage that required emergency decompressive craniotomy. Follow-up angiography confirmed persistent shunt occlusion. The patient was subsequently transferred to a rehabilitation facility with a modified Rankin Scale score of 4.

Conclusion: This case illustrates a rare instance of delayed hemorrhage after Onyx TAE for a tentorial DAVF, possibly related to venous outflow impairment after embolization. SWI may be a useful adjunctive imaging modality for the early detection of postoperative venous circulatory disturbance.