Concomitant rupture of an intracranial aneurysm and a dural arteriovenous fistula: Clinical image.

A patient in their 50s presented with postcoital severe headache. Computed tomography revealed a subarachnoid haemorrhage but also a subdural hematoma at the left convexity. CT angiography revealed a large irregular anterior communicating artery aneurysm but also cortical serpiginous vessels suggestive of a vascular malformation adjacent to the subdural hematoma in the left convexity. DSA confirmed the ruptured aneurysm but also revealed a Borden 3 type dural arteriovenous fistula on the left convexity. The fistula had arterial supply mostly from middle meningeal artery branches and venous drainage directly to a left cortical vein adjacent to superior sagittal sinus. Ruptured aneurysm was treated with coiling. The ruptured fistula was treated in the same session with transarterial Onyx embolization. Patient had a favourable outcome. Our case is an important reminder for all clinicians treating patients with intracranial hemorrhages on the necessity of fully reviewing all available preoperative imaging.