Spontaneous Thrombosis of a Middle Meningeal Arteriovenous Fistula With Subsequent Pseudoaneurysm Formation: Case Report and Review of Literature

Abstract

<jats:title>ABSTRACT</jats:title> <jats:sec> <jats:title>BACKGROUND AND IMPORTANCE</jats:title> <jats:p>Middle meningeal artery (MMA) pseudoaneurysms and middle meningeal arteriovenous fistulas (MMAVFs) are rarely reported after head injury. We report an unusual case of delayed MMA pseudoaneurysm formation after spontaneous thrombosis of an MMAVF, and review existing literature on MMAVF treatment and results.</jats:p> </jats:sec> <jats:sec> <jats:title>CLINICAL PRESENTATION</jats:title> <jats:p>A 59-yr-old male presented with a 5-d history of worsening left-sided headaches, followed by nausea, lethargy, and difficulty with speech. Non-contrast computed tomography demonstrated a left temporal intraparenchymal hemorrhage (IPH) and an acute left-sided subdural hematoma (SDH). Cerebral angiography found abnormal shunting between the right MMA and the right sphenoparietal sinus, consistent with an MMAVF. During the course of admission, the patient's neurological condition deteriorated requiring craniotomy for evacuation of SDH and IPH. Given the presumed incidental nature of the contralateral MMAVF, conservative management was recommended. Follow-up imaging 2 mo after surgery revealed spontaneous thrombosis of the right MMAV. Repeat imaging 5 mo later revealed an MMA pseudoaneurysm at the prior fistulous site, which was subsequently embolized with Onyx, occluding the pseudoaneurysm and the MMA both proximal and distal to the pseudoaneurysm.</jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSION</jats:title> <jats:p>Spontaneous thrombosis of an MMAVF is rare and only seen in 13.1% of cases. However, subsequent delayed formation of an MMA pseudoaneurysm has not been described. Our case therefore demonstrates that MMAVF thrombosis may not indicate complete healing of the underlying injury to the MMA, and suggests the need for continued follow-up of such lesions despite initial apparent resolution.</jats:p> </jats:sec>

Traumatic middle meningeal arteriovenous fistula presenting with long delayed-onset facial nerve palsy without temporal bone fracture: illustrative case

“…Regarding angiographic outcomes of traumatic MMAVFs, the reported spontaneous occlusion rate of traumatic MMAVF was 13% and decreased shunt flow was observed in 4.9% of cases before treatment. 13 In our case, too, preoperative angiography demonstrated decreased shunt flow of the MMAVF. Regarding clinical outcomes of traumatic MMAVFs, the reported rates of focal deficit, severe deficit, and death were 16.4%, 8.2%, and 6.6%, respectively.…”

“…Regarding clinical outcomes of traumatic MMAVFs, the reported rates of focal deficit, severe deficit, and death were 16.4%, 8.2%, and 6.6%, respectively. 13 Several previous reports have indicated that traumatic MMAVFs resulted in intraparenchymal hemorrhage, subarachnoid hemorrhage, or subdural hemorrhage. 3 , 8 , 26 , 37 , 38 Transarterial coil embolization for MMAVF is the most common treatment and is feasible, effective, and minimally invasive.…”

Inpatient re-rupture of a middle meningeal arteriovenous fistula after traumatic brain injury

“…The present case demonstrated how traumatic MMAVFs can present with IPH with lack of a notable subdural or extradural hematoma. Further, spontaneous thrombosis with complete healing of a MMAVF is rare and serial angiography is recommended [9] . Thus, we add to the existing literature that patients with IPH in the setting of a traumatic MMAVF stand to benefit from early treatment with transarterial embolization using a liquid embolic.…”

Intra-operative emergence of occult dural arteriovenous fistula after middle meningeal artery embolization for chronic subdural hematoma: Case report and literature review

“…Dural arteriovenous fistulae arising from the middle meningeal artery (MMA-dAVF) are rare; roughly 41 case reports yielding a total of 61 patients have been described since 1951 [1] . The majority of reported cases are traumatic or iatrogenic in nature [2 , 3] .…”

“…The majority of reported cases are traumatic or iatrogenic in nature [2 , 3] . MMA-dAVF have proven to be high-risk lesions that can lead to intracranial hemorrhage [1 , 2] . Although isolated reports of spontaneous resolution exist [4] , treatment is often indicated when MMA-dAVF are identified and is typically achieved by trans-arterial embolization of the fistula.…”