Introduction. Spontaneous acute subdural hematoma (ASDH) is rare and comprises 2.6% of all ASDH. In one recent study, only 178 spontaneous ASDH were documented. However, only 1 case was attributed to dural arteriovenous fistula (dAVF). Vascular malformations cause less than 10% of subarachnoid hemorrhage (SAH). Spontaneous ASDH and SAH occurring together are extremely rare. Literature is scarce on cases with dAVF of the occipital lobe as a cause of simultaneous spontaneous ASDH and SAH.

Objective. This paper aims to present a case of a spontaneous acute subdural hematoma and subarachnoid hemorrhage caused by a dural arteriovenous fistula of the occipital lobe, along with its clinical presentation, diagnosis, and treatment.

Case Summary. A 44-year-old Filipino male with no history of trauma presented with severe headache, vomiting, and decreasing sensorium – CT scan revealed acute parenchymal bleed in the left occipital lobe with subarachnoid extension and subdural hematoma in the left fronto-parieto-temporal convexity along the tentorium cerebelli and posterior interhemispheric falx. Due to the location of the lesion seen on the CT scan and the gender distribution, Arteriovenous malformation (AVM) was initially considered, thus proceeded to computed tomography angiogram (CTA) to establish the diagnosis of vascular anomaly, however, revealed dAVF instead. Four-vessel angiogram was done to assess the tributaries of the dAVF and confirmed the diagnosis. Complete obliteration of dAVF of the occipital lobe was done with Onyx Embolization in one session.

Conclusion. This is the first case of Borden type II, Cognard type IIa+IIb dAVF, as reported in this institution. Although extremely rare as a cause of SAH and ASDH, dAVF should be considered a differential diagnosis in patients with no identifiable common cause of the new onset of severe headache and poor neurologic status.

Key Words: spontaneous acute subdural hematoma, subarachnoid hemorrhage, intracranial dural arteriovenous fistula

1. Book: Sidawy, A. et al. (2019). Rutherford's vascular surgery and endovascular therapy 9th Ed. Chapter 27. Elsevier, Inc. Philadelphia
2. Book: Kasper, D., et al. 2015. Harrison's Principles of Internal Medicine. McGraw-Hill Education. USA
3. Article: Gupta, A. 2009.Intracranial dural arteriovenous fistulas. A review. Indian Journal of Radiology and Imaging. 191:43-48
4. Article: Khanna, L., Rohatgi, A., & Jha, N. 2013. Dural arteriovenous fistula. Journal of The Association of Physicians of India. 61:56-57
5. Article: Gomez, J., et al. 2011. Classification schemes of cranial dural arteriovenous fistulas. Neurosurgery Clinics of North America Journal. 23;55-62
6. Article: Cedro, O. & Villarosa, A. 2012. Medusa head: a case report of an extracranial arteriovenous malformation with multiple aneurysms. Philippine Heart Center Journal. 16(2): 84-89
7. Book: Daroff, R. et al. 2016. Bradley's Neurology in Clinical Practice, 7th Ed. Elsevier. Inc. China
8. Article: McBride, W. (2015). Subdural hematoma in adults: Etiology, clinical features, and diagnosis. J.L. Wilterdink (Ed.), UpToDate. Retrieved on September 22, 2018, from https://www.uptodate.com/contents/subdural-hematoma-in-adults-etiology-clinical-features-and-diagnosis.
9. Article: Komatsu, Y. et al. (1997). Subdural hematoma of arterial origin: report of three cases. No Shinkei Geka. 25(9):841
10. Article: Shekarchizadeh, A. et al. 2017. Acute Subdural Hematoma and Subarachnoid Hemorrhage Caused by Ruptured Cortical Artery Aneurysm: Case Report and Review of Literature. Adv Biomed Res. 6: 46
11. Article: Siddiq, F. (2013). Nonaneurysmal subarachnoid hemorrhage. J.L. Wilterdink (Ed.), UpToDate, Retrieved on September 22, 2018, from https://www.uptodate.com/contents/nonaneurysmal-subarachnoid-hemorrhage.
12. Article: Singer, R.J., et al. (2017). Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage. J.F. Dashe (Ed.), UpToDate. Retrieved on September 22, 2018, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-aneurysmal-subarachnoid-hemorrhage
13. Article: Kiyosue, H., et al. 2004. Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization. RadioGraphics. 24(6): 1637-1653
14. Article: Daniels, D. et. al. (2013). Intracranial hemorrhage from dural arteriovenous fistulas: clinical features and outcome. Neurosurg Focus. Vol 34(5): E15
15. Article: Singer, J. et al. (2018). Subarachnoid hemorrhage grading scales. JF Dashe (Ed.), UpToDate, Retrieved on October 15, 2018, from https://www.uptodate.com/contents/subarachnoid-hemorrhage-grading-scales.
16. Article: Malik, A.A., et al. (2018). ECOG performance status. Retrieved on October 15, 2018, from https://radiopaedia.org/articles/ecog-performance-status
17. Article: Li, C., et al. 2015. Clinical and angioarchitecture risk factors associated with intracranial hemorrhage in dural arteriovenous fistulas: a single-center retrospective study.PLoS One Vol 10(6)
18. Book: Winn, H. 2017. Youmans and Winn neurological surgery 7th Ed. Elsevier, Inc. Philadelphia
19. Article: Cognard, C., et al. 1995. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 194:671–680
20. Article: Borden, J., et al. 1995. A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg. 82:166–179
21. Article: Rooij, W., Sluzewski, M., & Beute, G. 2007. Brain AVM Embolization with Onyx. American Journal of Neuroradiology 28(1):172-177
22. Article: Hacking, C., et al. (2018). Dural arteriovenous fistula. Radiopaedia. Retrieved on September 22, 2018, from https://radiopaedia.org/articles/dural-arteriovenous-fistula
23. Article: Sadeh-Gonike, U. et al. (2017). Transarterial onyx embolization of intracranial dural fistulas: a prospective cohort, systematic review, and meta-analysis. Neurosurgery, 82(6):854-863