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Título

ATYPICAL DISCOVERY OF A CEREBRAL DURAL ARTERIOVENOUS FISTULA

RESUMO

A 35-year-old male with an acute history of recurrent seizures and decreased level of consciousness associated with high fever of unknown onset. He arrived at the emergency department with a Glasgow Coma Scale of 3 alongside automatism. Past medical history was remarkable for traumatic brain injury ten years prior to these events and a seven-months history of progressive impaired gait.
He was submitted to a brain computed tomography (CT) which showed cortical hypodensities, periventricular and symmetrical bilateral basal ganglia calcifications, venous engorgement due to an extensive arteriovenous fistula with brainstem involvement. Lumbar puncture showed a high open pressure, normal glucose levels, elevated white blood cell and protein counts. Cerebrospinal fluid cultures were positive for gram negative cocci. Prolonged EEG showed moderate to severe diffuse symmetrical baseline activity disorganization without epileptiform activity.
The patient evolved with refractory non-epileptic seizures and healthcare-associated infections and was then submitted to palliative care.
Intracranial dural arteriovenous fistulas (DAVFs) are abnormal connections between dural arteries and dural venous sinuses, meningeal veins or cortical veins and are responsible for 10-15% of all intracranial arteriovenous malformations. It can be related to trauma, dural sinus thrombosis, venous hypertension, previous craniotomy or mostly idiopathic aetiology. It is diagnosed preferably though conventional angiography, but CT and Magnetic Resonance (MR) can also be used, although they confer lower accuracy. After suspicions of DAVFs, additional evaluation with CT or MR angiography is needed to confirm. Most common locations in adults are at the cavernous, sigmoid and transverse sinuses. Most symptoms start around the fifth and sixth decades of life.
The pattern and location of the DAVF venous drainage is associated with its clinical presentation and severity. DAVFs are not a risk factor for meningitis or other central nervous system (CNS) infections. Gait impairment is more associated with spinal DAVF or brainstem DAVF.
Herein we present a case with a past history of gait impairment and a sudden onset of status epilepticus due to meningitis. Although CNS infections are not facilitated by DAVFs, it led to the discovery of an extensive one in our patient which already compromised cortical regions, which contributed partially to severity of the case despite treatment.