Neurochirurgia 29 (1986)

61

Neu rochirurg ia 29 (1986) 61 -62
@Georg Th ieme V('r1ag Stuu gart - 1'\'ew York

Summary

Chronic subdural
haematoma from cerebral
arteriovenous malformation
E. Pozzati, F. Tognetti, G. Gaist

In a review of 122 int racranial arteriovenou s malformatio ns (AVM s) c bserved berween 1970 and 1983. we
have fouod the ext remel y rare occur rence of a ehronic
subdural haematoma overlying a frontal AVM. In th is
case the picture of a presumed p rimar y epilepsy was complicated by symptoms of raised intracrani al pressu re,
which warraured admission and neuror adi ological examina tion.
The pathogenesis of rhe haem arom a is briefly discussed.

Division of Neu rosurgery, Ospedale Bellaria, Bologna/lraly

Intracranial bleeding is a complicarion of 40 to 80 % of cerebr al
AVM s, wirh haemorrhage occurring mo st frequently in the subarac hno id space andrer wirhin rhe cerebral pa rench yma (6,
9- 11,20). On rare but weil docu mented occasions blood ruptur es th e arac hno id membr a ne and accumu lat es acurely as weil
as massively in the subdural space (12, 15, 2 1).
Th e presence of discrere, pro gressive accumulati on of bloo d in
the suhd ura l space overlying a cereb ra l AVM is excep tiona l (16).
Thi s circumstance has been enco untered in one of o ur 122
reviewed cases o f the period 1970- 1983, in which the AVM 's
sympto ms were ove rlooked for several years until intracra nial
hypertension develop ed afrer a tri vial head injur y.
Cas e report
Thi s woman aged 35 yea rs wa s known ro suffer from gra nd mal seizu res
for ten years; epilepsy wa s pa rtially controlled by med ical rrear ment .
Pasr med ical hist ory was o therwis e non-contriburory . Sbe ca me to ou r
ob serv anon 25 da ys after a bead injury susrained du ring a seizu re; mild
obrundation had persi sted over the week s following injur y, alon g with
so me tr oubles o f speech arid a lefr-sided weakness.
Exa minatio n o n ad mission revealed a d rowsy , un coo perative panen t.
Mild neck stiffness and lefr hemiparesis were pre senr . The remaind er of
th e neu rological exa mina ton was nor mal.
Right ca ro nd angiogra phy showed no abno rmali ties in tbe ipsilateral
cerebra l hemi sphere, while th e ce ntrast med ium crossed the midli ne in
lar ge amounts a nd ou tli ned the left anrerio r circu lario n. An exrrace rebral avascul ar space, 3 cm in its ma jor rhickness, was dema rcated in the
left fronro-tem po ral con vexiry, ipsilare ral ro rhe hem ipare sis, with moderate shift o f bor h the anrerio r cerebral arre ries (ACAs) ro the righr side.
A ro undi sh area of parh ological circu larion lay wirhin rhe left frontal
lo be (Fig. 1).
Left ca roti d a ngiograp hy confi rmed a fro nta l AV~l. 5 x 4 x 4 cm in
size; th e lesion was fed by hype rtro phic fro ntal arteries fro m the Syh'ian
group and was dr ained rostrall y imo th e superio r sagittal sinus. Pro babi)'
due to stea l ph enom enon , the ipsilateral ACA wa s not shown (Fig. 2 ).
Th e patient un derwem a left fromal cra niotomy . After th e d ural flap was
elevat ed , a chro nic haemawma with amber-colo ured, semi-fluid co ntem
wa s di sco vered ; the colleetio n was evacu ated and th e inner capsule o f the
haematoma carefu lly separa ted from th e con ical surface. Th e AVM was
reseeted co mplete ly.
Th e pa tient exh ibited non-flu em aphasia as a posto perat ive complication . Co nt rol ca ro tid angiography confirmed both th e comp lete ob lite ration o f the AVM and the re-expan sio n of the left cerebral hemi sphere.
Bo th th e aphasia an d the left hem iparesis showed stead )' impro vement
over the ensui ng days u nt il d ischa rge.
At the time o f wr itin g, so me years afte r operation, th e patient remains
seizure -free and aphasie spe ils ar e the o nly eomplaint.

Bei einer Überprüfung vo n 122 intrak rani ellen a rteriovenösen Fehlbildun gen a us denjah ren 1970- 1983 entdeckten wir den ä ußerst seltenen Fall eines chro nischen subduralen Hämatoms. das eine front ale arteriovenöse M ißbildun g überl ager te. In diesem Fall wa r das Bild einer a ngeno mmenen prim ären Epilepsie durch Symptome eines erhöhten Schädelin nendrucks kompliziert. wod urch sowohl die Einweisung als auch die neuroradiologische Untersu chung erforderlich wurden . Die Pathogenese des H ämatoms wird kurz besprochen.
Key-Words: Cerebral a rterioveno us mal Formation - Ch ro nic
su bdural haematoma

Discussion
The occurrence of sub dural haemorr hage com plicaring a cerebral vascular ma lformation is unu sual. In these cases rhe most
common source of bleeding is a ruprured berry a neurys m, particularl y of the inter nal caroti d or middle cereb ral ar teries (1, 2.
4, 7, 8,13, 14, 18).
Direct subdural haemorrhage from a cerebral AVM is very ra re.
Rengocbary and Szymanski recently reported two instances of
acute subdura l haem atoma (rra umatic in one case and proba bly
spon taneou s in rhe other one ) telared to an AVM (12). and
reviewed the older lirera ture findin g a few ear lier cases (15, 2 1).
T0 our kn owled ge, the onl y case so fa r o f a chr onic subdur al
haem atoma complicating an AVM has been describ ed in the
Ge rma n liters tu re by Sche rzer (16). In thi s case, also pr obably
occurring as in o ur pati ent a t the mom ent of a gra nd mal seizure,
head injury resulted in some damage and blood ooz ing from the
path ological vessels of the malformation .
Chronic accumulation of blood in the subdural space is usu ally
..,oenous in origin, and is gene rally seen in traumatic chr onic
haem atomas fro m cerebral bridging veins. However. a n arterial
so urce of chronic haematoma has also been demo nstrat ed by
Byun and Patel in one of their rwo cases of sponta neous subdural
bleeding (3). a finding wh ich ha s been referred to as ext remely
ra re (19).
In our patient the source ofhaemorrhage cou ld not be identified.
since the lesion had alrea dy evolved to the chro nic ph ase with
lysis of the subdural c10ts and healing of the ruptu red surface
vesse!. Apart from their ultima te (i. e. arterial or veno us) or igin,
wide con sensus exists rega rding the pathogenesis of sponta neous subdural haematomas: the presence o f localized adhesions

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Chro nisches subdurales Hämatom durch zerebrale a rterioven öse Fehlbildung

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Neurochirurgia 29 (1986)

E. Pczzati, F. Tognetti, G. Gaist
berween tbe ara chnoi d membrane and a corti cal vessel at the
ruptu re site is critical for bleeding to occur dir ectly inro the
subdural rat her than the subarachnoid space (3, 5 , 12, 17, 19).
In our case we suggest that, given the existence of a locus minoris
resistenti ae creared by a cortical-arachnoida l fusion so mewhere
in th e ar ea of rhe AVM, even a mild head injury resulting in
minor moti on of th e bra in caused tearing of rhe arachno id
membrane and tr iggered a pro gressive subdural bleeding (3).

(1)Bassttt, R. c., Lj.lemm('n : Sub du ral ha emar oma associared with
bleedi ng intracr an ial a neurysm. ] .
Neu ros urg. 9 (1952 ) 443-450
(2) Boop, W. C. ir., S. N . Chou, l. A.
Prench : Ruprured intra cranial a neu rysm cornplicated by su bdu ral ha ema roma . J. Neu rosu rg. 18 (196 1) 83 4-836

Fig. 1

Right irrtemal carotid ang iography. w ith cro ss-üllinq and cutlin ing of the contralate ral circulat ion . A fett ext racerebra l evaseurer space
(arrowheads)with m idline shitt to t he right side is visible. al009 w ith
" clcudv " staining of the fett fro ntal reg ion tarrowl.

(3) Byun, H. S., P. P. Parel: Spontaneo us su bd ural haem aro ma o f ar terial
origi n : Report of rwo cases.
Neu ro su rgery 5 (19 79 ) 61 1--6 13
(4) Clarke, E.,j. N. Wa lron: Subd ura l
ha ema roma complicari ng im racrani a l
a neurysm a nd angioma. Brain 76

(1' 531378-404
(5) Fein.]. M .: Co mment to Byun and
Pa tel (Ref 3)
(6 ) Gu idett i, B., A. Deiit ala . lm racra nial arteriovenous ma lfo rma t jons.
Co nserva rive a nd surgical trea tment. J.
Neu ros urg.53 (1980) 149-152
(7) H andd , S. F.,F . O. l. Perpetuo, C.
H . Handel: Subd ural haema tcma d ue
to rupt ured cere bral a neurysms :
Angiograph ic d iagnos is a rid po tenti al
A.j.R. 130 (197 8 ) 507pitfa ll fo r

cr.

50.
(8) King,J. E. J.: Ha emato mas:,Ext radu ral, subdura l a nd subcomcal.
Am . J. Surg . 5 9 (1943) 24 8-27 1
(9) M ingrino, S.: Suprat entorial arreriovenous malfonnatio ns of rhe
brain, in Kray enb ühl, H . (ed .): Ad vances and techrucal standa rds in
Neu rosu rgery . Wien/N ew York,
Spr inge r (197 8), Vol. 5,93--123
(10) O livecrona , H .,). Lad enh eim.
Ccngeniral art eriovenous aneurysms
of rhe ca rond a nd verte br al a rterial sysrem s. Berlin, Spri nger (195 7 )
(11 ) Perret, G., H . N ishio ka : Arteriovenou s malfo rma tio ns. An a na lysis of
545 case-sof cra nio-ce rebral an erio-

Fig. 2 Le tl internal carot id angiog raphy. Due toa ste al phenomenon
the w ho te hemi spheric circulat ion appea rs to be concent rated " in the
f ron tal AVM . Also the leftACA is not filled.
N

D, . Eugenio POz;:olti
Divisione di Nntrochirurgia

Ospedafe Bellaria
40 139 Bologn.2 flt.2ly

venous mal fo rmarions a nd fisrulae reperred rc rhe Ccoperarive Srudy. J.
Neu rosorg. 25 (1966) 467-490
(1 2) Rengacha ry, S. S., D. C. Szyma nski: Subdural hae maromas of arrerial
o rigin. Ne urosurgery 8 (198 1) 1 6 ~
172
(13) Ryan, E. P.: Rupture ofint racra nia l aneur ysrn r ausing acure su bdura l
hem atcma, intr atempo ral herna torn a,
and dece reb ratio n, with surv ival: Case
repo n.Neu ros urgerv 5 (1979) 698 -

700
(14) Sachs, E. jr., J. L Bem at: Recovery
from acut e subd ura l hem atoma and
unca l hemi ation due to ruptu red inrracramal a neurysm. Neu rosu rgery 3
(1978 ) 66--67
(15) Sano. K., Y. Ueda , l.Sa uo : Sub a rachnoid haemorr hage in child ren.
Ch ild's Brai n 4 (19 78) 38-46
(16) Scherzet, E.: Ch ro nicsubdura l
haematorna in va scula r malformarion s
o f the mrracran ium . Wr . Z. Ne rvenhk.
25 (1967) 5 7--67 {t ra nsl.l
(17) So meda, K., N . Yas ui, Y.
M ori waki , Y. Ka warnura, H . Marsumur a: Ext ravasarion o f co ntrast mat eria l
into sub d ural space from intemal
carond aneurysm du ring a ngiogr.aph y.
Case repo rt . J. Neurosu rg. 42 (1975)
473-477
(18) Stra ng, R. R., D. Tovi, R. Hugosson : Subdur.alhaematomas resu lting
fro m rhe ruprureof intracr.ani.al.aneri.a l
a neurysms. Aet.aChi r. Scand. 12 1

(1'6 11345- 350
(19 ) Tatcr, C. H.: Co mment w Byun
a nd Parel (Ref. 3)
(20) T rum py, J. H ., P. Eldevik : Intra cra nia l arre riove no us ma ltorma tio ns:
Co nservanv e o r surgical t reatment ?
Surg. Neu ro l. 8 (19 77 ) 17 1-175
(2 1) Voris, H . C.: Subdu ra l ha ematoma.JAMA 13 2 (1946) 686--6 92

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References