Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, USA.
Department of Neurosurgery, North Shore University Hospital, Manhasset, New York, USA.
World Neurosurg. 2019 Jun;126:171. doi: 10.1016/j.wneu.2019.02.185. Epub 2019 Mar 9.
Dural arteriovenous fistulas (dAVFs) are rare vascular malformations of uncertain pathophysiology. If associated with cortical venous reflux, they present a significant risk of hemorrhage. We present a 69-year-old patient who presented with spontaneous right-sided symptomatic chronic subdural hematoma, which was evacuated via burr hole. Due to lack of history of prior trauma, computer tomography angiography was performed, which showed dilated convoluted vessels in the right occipital region and an enlarged right posterior cerebral artery, suspected to be an arteriovenous malformation or dAVF. Subsequent angiography demonstrated occipital tentorial dAVF with primary cortical venous reflux (Cognard III) and reflux into the transverse sinus, fed primarily from the petrosquamous branch of the middle meningeal artery and neuromeningeal trunk. The fistula was initially treated by transarterial endovascular embolization of the occipital artery and neuromeningeal trunk with Onyx, achieving complete obliteration. However, follow-up angiography demonstrated recurrence of the lesion fed from the contralateral middle meningeal artery and pial branches of the enlarged right posterior cerebral artery. Given the recruitment of the contralateral supply from the left middle meningeal artery and ipsilateral posterior cerebral artery, we felt that surgical disconnection of the fistula was the best option for the patient. An occipital craniotomy with disconnection of the fistula without isolation of the transverse sinus was performed (Video 1), as published literature demonstrated lower intraoperative risk with disconnection only. The perioperative course was uneventful. Immediate postoperative and follow-up angiography demonstrated complete occlusion of the fistula.
硬脑膜动静脉瘘（dAVF）是一种发病机制尚不清楚的罕见血管畸形。如果伴有皮质静脉反流，会显著增加出血风险。我们报告了一例 69 岁患者，因自发性右侧症状性慢性硬膜下血肿就诊，血肿通过颅骨钻孔清除。由于缺乏既往外伤史，行计算机断层血管造影（CTA）检查，显示右侧枕叶区迂曲扩张的血管，右侧大脑后动脉增粗，疑似动静脉畸形或 dAVF。随后的血管造影显示枕骨天幕 dAVF，存在原发性皮质静脉反流（Cognard III），并反流至横窦，主要由脑膜中动脉岩鳞支和脑膜神经干供血。该瘘首先通过动脉内血管内栓塞治疗，使用 Onyx 栓塞枕动脉和脑膜神经干，实现完全闭塞。然而，随访血管造影显示病变由对侧脑膜中动脉和增大的右侧大脑后动脉脑皮支供血复发。鉴于对侧供血来自左侧脑膜中动脉和同侧大脑后动脉，我们认为手术切断瘘管是该患者的最佳选择。行枕骨开颅术，切断瘘管而不隔离横窦（视频 1），因为文献报道仅切断瘘管的术中风险较低。围手术期过程无并发症。术后即刻和随访血管造影显示瘘管完全闭塞。
