Angiographically Silent Ruptured Dural Arteriovenous Fistula Presenting As Subdural Hematoma

Dural arteriovenous fistulas (dAVF) are aberrant vascular communications that can have devastating effects ranging from headaches to death. Typically, these malformations are identifiable on a CT angiogram (CTA) and confirmed via catheter angiography. We present a case of a female patient who presented with a headache and was found to have a large holohemispheric subdural hematoma. Given the lack of trauma, a CTA was performed. The CTA revealed abnormal vessels in the anterior temporal lobe spanning her hematoma. A diagnostic cerebral angiogram was performed; no early venous drainage was detected. When the patient was taken to the operating room for subdural hematoma evacuation, an aberrant connection from a superficial cortical vein to the middle meningeal artery was identified and ligated. Although rare, this case demonstrates that patients can present with ruptured vascular malformations that are radiographically silent on cerebral angiography.