title: Concurrent cervical dural and multiple perimedullary arteriovenous fistulas presenting with subarachnoid hemorrhage: The source of bleeding was invisible at initial angiography.
abstract: BACKGROUND
  We report the concurrence of a spinal dural arteriovenous fistula (DAVF) and multiple perimedullary arteriovenous fistulas (PAVFs) presenting with subarachnoid hemorrhage (SAH). Moreover, the bleeding site was detected 1 month after onset.
  
  
  METHODS
  A 56-year-old man was admitted to our hospital with an SAH. A DAVF and two PAVFs were detected at the C2 level by two rounds of digital subtraction angiography. The source of bleeding, an aneurysm on the feeding artery of PAVF, was detected at the second angiogram, which was performed 1 month after the onset of SAH. The aneurysm was not demonstrated at initial angiogram because of thrombosis in the aneurysm. The DAVF was interrupted by transarterial embolization, and the two PAVFs were subsequently treated with surgery.
  
  
  CONCLUSIONS
  A part of the whole AVFs or the source of bleeding may be invisible in the acute stage just after hemorrhage. Repeated angiography is necessary to diagnose such complex AVFs especially in case of an SAH and treatment should be performed during the subacute stage.
authors.affiliation: Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan.
authors.forename: Iku
authors.initials: I
authors.lastname: Nambu
authors.affiliation: Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan.
authors.forename: Naoyuki
authors.initials: N
authors.lastname: Uchiyama
authors.affiliation: Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan.
authors.forename: Kouichi
authors.initials: K
authors.lastname: Misaki
authors.affiliation: Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan.
authors.forename: Masanao
authors.initials: M
authors.lastname: Mohri
authors.affiliation: Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Ishikawa, Japan.
authors.forename: Mitsutoshi
authors.initials: M
authors.lastname: Nakada
keywords: Digital subtraction angiography; spinal dural arteriovenous fistula; spinal perimedullary arteriovenous fistula; subarachnoid hemorrhage