Sakata Hiroyuki, Nishimura Shinjitsu, Mino Masaki, Hori Emiko, Fujita Tomoaki, Midorikawa Hiroshi, Kaimori Mitsuomi, Nishijima Michiharu
Department of Neurosurgery, Aomori Prefectural Central Hospital, Aomori, Japan.
Neurol Med Chir (Tokyo). 2009 Oct;49(10):462-4. doi: 10.2176/nmc.49.462.
A 48-year-old woman suffered head trauma and presented with an acute epidural hematoma with a linear fracture of the right temporal bone across the middle meningeal groove. Initial angiography demonstrated no vascular abnormalities. Eight months later, she again suffered head trauma and computed tomography demonstrated traumatic subarachnoid hemorrhage. Right external carotid angiography revealed a middle meningeal arteriovenous fistula (AVF) which drained into the superficial sylvian veins via the sphenoparietal sinus. Serial angiography showed progressive dilation of the draining veins, but she refused surgical intervention and dropped out of our outpatient clinic. Fifteen years after the first head trauma, she presented with subarachnoid hemorrhage. Angiography demonstrated formation of venous aneurysms on the drainer of the AVF. The dilated superficial sylvian vein was removed together with the ruptured venous aneurysm. Histological examination of the drainer revealed an arterialized vein. The serial angiographic evaluations revealed dynamic changes of the traumatic middle meningeal AVF, including progressive dilation of the drainers, simplification of the drainage routes, and the formation of venous aneurysms, which presumably represents the entire natural course of traumatic middle meningeal AVF manifesting as hemorrhage. The present case of traumatic middle meningeal AVF with a deteriorating course suggests that surgical removal or embolization of the AVF is strongly indicated if follow-up angiography shows dilation of the drainers, which implies increased shunt flow.
一名48岁女性头部外伤，出现急性硬膜外血肿，右侧颞骨线性骨折，骨折线跨过脑膜中动脉沟。初次血管造影未显示血管异常。8个月后，她再次头部外伤，计算机断层扫描显示外伤性蛛网膜下腔出血。右侧颈外动脉血管造影显示一个脑膜中动静脉瘘（AVF），通过蝶顶窦引流至大脑外侧浅静脉。系列血管造影显示引流静脉逐渐扩张，但她拒绝手术干预并退出了我们的门诊。首次头部外伤15年后，她出现蛛网膜下腔出血。血管造影显示AVF引流处形成静脉瘤。扩张的大脑外侧浅静脉与破裂的静脉瘤一起被切除。对引流处的组织学检查显示为动脉化静脉。系列血管造影评估揭示了外伤性脑膜中AVF的动态变化，包括引流处逐渐扩张、引流途径简化以及静脉瘤形成，这可能代表了外伤性脑膜中AVF以出血为表现的整个自然病程。本例病程恶化的外伤性脑膜中AVF表明，如果随访血管造影显示引流处扩张，提示分流流量增加，则强烈建议手术切除或栓塞AVF。
