Middle Meningeal Arteriovenous Fistula After Contralateral Head Trauma: A Case Report

Abstract Traumatic middle meningeal arteriovenous fistula (MMAVF) is an uncommon vascular lesion that most commonly develops beneath a skull fracture at the site of impact. MMAVF caused by contrecoup injury without skull fracture is rare and may present diagnostic and therapeutic challenges. We report a 59-year-old woman who developed a contrecoup MMAVF after head trauma without skull fracture. Initially, she complained of right occipital pulsatile pain at the site of impact. Five days later, this resolved and was replaced by left frontal tightening headache accompanied by pulsatile tinnitus. Magnetic resonance angiography demonstrated abnormal enlargement of the left middle meningeal vascular structures, and digital subtraction angiography confirmed an MMAVF immediately distal to the foramen spinosum with multiple venous drainage pathways. Selective transarterial coil embolization targeting the shunt point achieved complete obliteration without complications. This case highlights that evolution in the location and quality of posttraumatic headache may provide an important diagnostic clue for MMAVF. In contrecoup lesions near the foramen spinosum, careful identification of the shunt point and awareness of potentially dangerous anastomoses are essential for safe and effective endovascular management.