A rare case of multiple high-grade dural arteriovenous fistulas manifesting as progressive confusion and abnormal behavior.

INTRODUCTION AND IMPORTANCE: Multiple dural arteriovenous fistulas (AVFs) are rare intracranial vascular malformations with fatal consequences. Patients usually manifest with variable clinical presentations, which depend on the fistula's size, location, and the development of complication. Digital subtraction angiography continues to be the gold standard neuroimaging modality for diagnosis.

CASE PRESENTATION: A 47-year-old female patient was transferred from Gaza Hospital intubated under complete sedation after she had progressive confusion and abnormal behaviors. She was immediately admitted to our surgical ICU. Brain computed tomography angiography was done and showed middle and posterior cranial fossae high flow dural AVFs with grad IV Cognard classification. Also, right petrosal venous sinuses thrombosis, secondary brain edema and herniation were found. Cerebral catheterization revealed multiple dural AVFs with all branches of external carotid arteries and other branches from vertebral arteries fistulized into the transverse dural sinus, superior sagittal sinus, and sigmoid sinus.

CLINICAL DISCUSSION: Even though they are rare multiple dural AVFs do exist, and it is importance to consider while assessing patients who have symptoms that could point to arteriovenous fistulas. Early diagnosis and prompt intervention is a crucial step in such cases.

CONCLUSION: Multiple dural AVFs are rare conditions that are challenging, especially in low-middle-income countries where expertise and clinical resources are limited. A delay in the diagnosis may result in considerable morbidity and mortality.