Atypical dural arteriovenous fistula associated with meningitis

A 49-year-old male presented with hemisensory disturbance and gait unsteadiness following a previous episode of meningitis. He had no contributory medical or head injury history. Magnetic resonance imaging revealed innumerable medullary vessels in the white matter of the left cerebral hemisphere, which had not been recognized in the previous imaging study. Cerebral angiography showed variant superior sagittal sinus (SSS) arteriovenous fistula (AVF) fed by the bilateral middle meningeal and superficial temporal arteries, and drained directly to the cortical veins with marked venous engorgement in the affected hemisphere. The fistulas were located on the cortical veins, apart from the SSS. Initial percutaneous transarterial embolization failed, so the AVF was completely obliterated with a combination of surgical and endovascular techniques. The symptoms ameliorated postoperatively. Meningitis may be an underlying pathology of dural AVF. Variant SSS AVF can be treated with a combination of surgical and endovascular techniques.