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 of the middle meningeal artery (MMA-dAVF) are high risk lesions that can lead to intracranial hemorrhage. We describe the case of an adult male that presented with chronic subdural hematomas and was treated with burr hole craniotomy plus middle meningeal artery (MMA) embolization. Although the pre-embolization angiogram showed no signs of a fistula, a fistula arising from the MMA and draining into the superior sagittal sinus emerged intra-operatively. To our knowledge, this is the first case of intra-operative emergence of occult MMA-dAVF with intracranial drainage during MMA embolization for chronic subdural hematoma treatment. This observation supports monitoring for and embolizing spontaneous MMA-dAVF following MMA embolization.