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Hemorrhagic changes in a dural arteriovenous fistula are typically associated with cortical venous reflux and occur as intracerebral or subarachnoid hemorrhages. A convexity dural arteriovenous fistula (DAVF) usually flows directly into the cortical veins and exhibits cortical venous reflux. Herein, we report a rare case of a convexity DAVF without cortical venous reflux presenting with a pure acute subdural hematoma. A 19-year-old man complaining of headache without any history of head injury was diagnosed with a left acute subdural hematoma on magnetic resonance imaging (MRI) and referred to our hospital. The patient was conscious and exhibited no neurological signs. The MRI did not reveal any possible abnormalities leading to hemorrhage. Cerebral angiography revealed a dural arteriovenous fistula in the left parietal cranium with a feeder from the middle meningeal artery and a drainer into the main transverse sinus via a diploic vein. Part of the shunt blood flowed into the superior sagittal sinus from the meningeal vein; however, there was no reflux into the cortical vein or stasis of the cerebral vein, suggesting venous hypertension. A convexity DAVF was diagnosed as the source of bleeding, and transarterial embolization was performed. The patient recovered without any neurological deficits. In the absence of trauma, an acute subdural hematoma requires an appropriate evaluation of the vascular lesions and a treatment plan., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Japan Neurosurgical Society.)

A 66-year-old woman who was previously diagnosed with idiopathic thrombocytopenic purpura (ITP) presented with mild right-sided hemiparesis and drowsiness. Head computed tomography (CT) imaging demonstrated a massive left chronic subdural hematoma (CSDH) with a midline shift. Because initial laboratory data showed a significantly decreased blood platelet count (0.3 × 10 4 /mm 3 ), medical treatments such as platelet transfusion, intravenous immunoglobulin (IVIG), and high-dose corticosteroid therapy, were initiated. She clinically and radiologically responded well to these treatments without any surgical intervention. In addition to presenting our case, we searched the PubMed and Ichushi Web databases to comprehensively illustrate clinical characteristics and treatment outcomes of similar cases. Including the present case, we found 19 reports and 23 cases of CSDH associated with ITP in the literature, and assessed 17 reports and 21 cases that were written in English and Japanese. None or mild neurological symptom were seen in 13 cases, and severe, such as coma and hemiparesis, were described in the younger 8 cases with significant difference. All except one were first treated with medical therapies. Most cases of the former group responded well to conservative therapy. On the other hand, most in the latter eventually needed surgical treatment in addition except recent two cases including the present case. CSDH associated with ITP is rarely described, and its management remains controversial. However, this report highlights multiple continuous medical treatments under strict observation and general care might be a useful alternative to avoid surgery in cases presenting with severe neurological deficits and extremely low platelet counts., Competing Interests: Conflicts of Interest Disclosure All authors have no conflicts of interests to declare.