Image Diagnosis: Encephalopathy Resulting from Dural Arteriovenous Fistula.

CASE REPORT A 69-year-old woman presented to the Neurology Department with 2 months of progressive psychomotor slowing, inability to concentrate, and periods of disorientation. Her past medical history was unremarkable, and she was taking no medication. There was no history of trauma. On neurologic examination she was alert but taking a long time to answer, apathetic, distractable, and hypophonic with right visual and sensitive hemiextinction and left hemiparesis. Montreal Cognitive Assessment Exam score was 11/30. A computed tomography scan of the brain (Figure 1) showed possible convexity subarachnoid hemorrhage that the brain magnetic resonange imaging (MRI)/MRI angiography (Figures 2 and 3) revealed to be engorged cerebral vessels. Hyperintensity in the deep white matter of the cerebral hemispheres was also present. Cerebral angiography (Figure 4) revealed a dural arteriovenous fistula (DAVF) of the superior sagittal sinus and torcula (Cognard classification IIb1). The patient underwent endovascular embolization, with combined transarterial (n-butyl-cyanoacrylate) and transvenous (coils) approach, resulting in proximal occlusion of the superior sagital sinus, torcula, and transverse sinus (Figure 5). Posttreatment angiography revealed near complete DAVF occlusion (Figure 6). Control MRI revealed a marked decrease of the deep white matter hyperintensity and no engorged cerebral veins (Figures 7 and 8). The patient’s mental status improved post procedure (Montreal Cognitive Assessment Exam score, 20/30), and she progressively came back to her baseline.