Nishiyama Hirokazu, Matsumoto Hiroyuki, Tetsuo Yoshiaki, Takemoto Hideki, Nakao Naoyuki
Department of Neurological Surgery, Kishiwada Tokushukai Hospital.
No Shinkei Geka. 2017 Aug;45(8):699-705. doi: 10.11477/mf.1436203577.
We report a case of tentorial dural arteriovenous fistula(dAVF)treated with transarterial and transvenous embolization using n-butyl-2-cyanoacrylate(NBCA). A 70-year-old man presented with dysarthria and trunk ataxia. Computed tomography(CT)on admission revealed right cerebellar hemorrhage. Right external carotid angiography demonstrated a tentorial dAVF fed by the marginal tentorial artery, petrosquamous branch of the middle meningeal artery, ascending pharyngeal artery, and artery of foramen rotundum. Right internal carotid angiography demonstrated a shunt fed by the meningohypophyseal trunk. The draining vein was the right basal vein with a varix, which drained into the straight sinus. Thin-slice axial images on magnetic resonance angiography demonstrated a shunt point located on the right tentorial incisura. The lesion was diagnosed as Cognard type IV tentorial dAVF. It was initially treated with transarterial embolization using 25% NBCA, which was injected into the marginal tentorial artery and the petrosquamous branch of the middle meningeal artery. However, owing to partial persistence of the shunt after the procedure, transvenous embolization using NBCA was performed. A microcatheter was navigated through the straight sinus into the basal vein, and a balloon catheter was also navigated to the confluence of the straight sinus and the basal vein to interrupt blood flow and prevent the NBCA from flowing back to the sinus. 80% NBCA was injected into the draining vein near the shunt point. Angiography performed immediately after the procedure revealed complete occlusion of the shunt, and postoperative CT showed no evidence of hemorrhage. Transvenous embolization of tentorial dAVF can be an effective method if a microcatheter can be safely advanced close to the shunt point.
我们报告1例经动脉和经静脉使用氰基丙烯酸正丁酯（NBCA）栓塞治疗的小脑幕硬脑膜动静脉瘘（dAVF）。1名70岁男性，表现为构音障碍和躯干共济失调。入院时计算机断层扫描（CT）显示右侧小脑出血。右侧颈外动脉血管造影显示，小脑幕dAVF由小脑幕缘动脉、脑膜中动脉岩鳞支、咽升动脉和圆孔动脉供血。右侧颈内动脉血管造影显示，分流由脑膜垂体干供血。引流静脉为右侧基底静脉伴静脉曲张，引流至直窦。磁共振血管造影的薄层轴位图像显示分流点位于右侧小脑幕切迹。该病变诊断为Cognard IV型小脑幕dAVF。最初采用经动脉栓塞治疗，将25%的NBCA注入小脑幕缘动脉和脑膜中动脉岩鳞支。然而，由于术后分流部分持续存在，遂行经静脉NBCA栓塞。将微导管经直窦送入基底静脉，同时将球囊导管也送至直窦与基底静脉汇合处，以阻断血流，防止NBCA回流至窦内。将80%的NBCA注入分流点附近的引流静脉。术后立即进行的血管造影显示分流完全闭塞，术后CT显示无出血迹象。如果微导管能够安全地推进至靠近分流点的位置，经静脉栓塞小脑幕dAVF可能是一种有效的方法。
