Nishimura Yusuke, Imai Keisuke, Hamanaka Masashi, Yamazaki Hidekazu, Nakanouchi Tsuneyuki, Kimura Masayoshi
Department of Neurology and Stroke Treatment, Kyoto First Red Cross Hospital.
Department of Neurology, Kyoto Prefectural University of Medicine.
Rinsho Shinkeigaku. 2020 Sep 29;60(9):620-626. doi: 10.5692/clinicalneurol.cn-001450. Epub 2020 Aug 8.
A 72-year-old man on hemodialysis for 7 years with end-stage renal disease was admitted to our institution due to an acute headache. Physical examination revealed normal signs except for noise on the back of his neck. His head CT and brain MRI showed no abnormal findings, while his MRA demonstrated abnormal signals in the left transverse to sigmoid sinus (T-S) suggesting a left dural arteriovenous fistula. After admission, his headache persisted and left orbital numbness also occurred. His digital subtraction angiography performed on the 5th day after admission showed no vascular malformation of either the T-S or cavernous sinus (CS). However, it showed occlusion of the left brachiocephalic vein (BCV) and the origin of the left internal jugular vein (IJV) resulting in intracranial venous reflux. These findings indicated the possibility that his acute headache was caused by intracranial venous reflux and increase of intracranial pressure resulting from the occlusion of the BCV ipsilateral to a dialysis shunt. Percutaneous transluminal angioplasty (PTA) for occlusion of the left BCV was performed on the 9th day and successful dilation of the lesion with a residual stenotic ratio less than 30 percent was obtained. After the angioplasty, venous reflux to the intracranial vein was markedly reduced and his headache and orbital numbness disappeared. One day after the procedure, MRA demonstrated the disappearance of the abnormal signals of the left T-S. Twelve months after discharge, he felt discomfort in the left of his face and the re-occlusion of the left VCV was demonstrated by angiography, therefore he received re-PTA. We recommend that physicians consider occlusion of the BCV ipsilateral to a dialysis shunt and intracranial venous reflux as a cause of acute headache in patients on hemodialysis.
一名因终末期肾病接受血液透析7年的72岁男性因急性头痛入住我院。体格检查发现除颈部后方有杂音外，其他体征均正常。他的头部CT和脑部MRI未发现异常，而磁共振血管造影（MRA）显示左侧横窦至乙状窦（T-S）有异常信号，提示左侧硬脑膜动静脉瘘。入院后，他的头痛持续存在，并且出现了左侧眼眶麻木。入院后第5天进行的数字减影血管造影显示T-S或海绵窦（CS）均无血管畸形。然而，它显示左头臂静脉（BCV）和左颈内静脉（IJV）起始部闭塞，导致颅内静脉回流。这些发现表明，他的急性头痛可能是由颅内静脉回流以及透析分流同侧的BCV闭塞导致颅内压升高引起的。在第9天对闭塞的左BCV进行了经皮腔内血管成形术（PTA），病变成功扩张，残余狭窄率小于30%。血管成形术后，颅内静脉的静脉回流明显减少，他的头痛和眼眶麻木消失。术后一天，MRA显示左侧T-S的异常信号消失。出院12个月后，他感到左侧面部不适，血管造影显示左VCV再次闭塞，因此他接受了再次PTA。我们建议医生将透析分流同侧的BCV闭塞和颅内静脉回流视为血液透析患者急性头痛的一个原因。
