Varix Rupture Due to High-Flow Parasagittal Sinus Dural Arteriovenous Fistula: A Case Report and Literature Review

Parasagittal sinus dural arteriovenous fistulas (DAVFs) are rare and aggressive vascular malformations with a high risk of intracranial hemorrhage (ICH). We present the case of a 75-year-old man with altered consciousness, anisocoria, and left hemiparesis due to a large subcortical ICH. Imaging revealed a ruptured varix associated with a parasagittal sinus DAVF (Cognard type IV, Borden type III). The patient underwent emergency hematoma evacuation, followed by successful transarterial embolization via the contralateral middle meningeal artery (MMA) using N-butyl-2-cyanoacrylate. Despite complete angiographic obliteration, the clinical outcome was poor. Parasagittal sinus DAVFs should be considered in the differential diagnosis of large subcortical hemorrhages. It should also be noted that certain cases may result in unfavorable clinical outcomes. When ipsilateral arterial access is unavailable, a contralateral approach via the MMA can be effective.