A case of traumatic intracerebral hematoma with dural arteriovenous fistula treated with endovascular treatment and craniotomy in hybrid operating room

Abstract

A 51–year–old man with a head injury was taken to our hospital. The patient showed loss of consciousness and right–sided paralysis. Head computed tomo­graphy (CT) detected left fronto–parietal lobe hematoma and midline shift. At initial imaging, CT angiography (CTA) revealed no obvious vascular malformations or arteriovenous shunts. Although the cause of hemorrhage was unknown, a skull fracture with subcutaneous left parietal hematoma was observed. Therefore, the hemorrhage was determined as a traumatic intra­cerebral hematoma. Hematoma removal was performed to save the patient’s life. The fracture line extended to the superior sagittal sinus (SSS) and there were concerns about occurrence of sinus laceration due to craniotomy. Thus, digital subtraction angiography (DSA) was performed in a hybrid operating room to determine the cause of hemorrhage under general anesthesia. Furthermore, DSA revealed a shunt near the SSS, which was diagnosed as a dual arteriovenous fistula (dAVF). Since the shunt point was located just below the fracture site, the shunt appeared to be a traumatic dAVF. Prior to hematoma removal, we decided to perform trans–arterial emboliza­tion using Onyx^TM liquid embolic agent (Onyx). The shunt was resolved after injecting 0.59 cc of Onyx via the left middle meningeal artery. Moreover, craniotomy was continued for hematoma removal. After incising the dura, a contused brain filled with hematoma and subarachnoid hemorrhage was observed. The hematoma was removed as far as possible under the microscope. The bone fragments were returned and the wound was closed after confirming adequate de­compression. After intensive care, the patient was transferred to a rehabilitation hospital with a modified Rankin Scale of 4. Herein, we encountered a case of traumatic intracerebral hematoma with dAVF that was treated with hematoma removal after endovascular therapy. Even in cases of intracerebral hematoma caused by head trauma, it is important to inspect for any vascular abnormalities. Furthermore, the hybrid operating room might be an effective tool particularly for patients with traumas who require vascular evaluation, endovascular treatment, and craniotomy in a single procedure.