Araki K, Nakahara I, Taki W, Sakai N, Irie K, Isaka F, Ohwaki H, Kikuchi H
Department of Neurosurgery, Faculty of Medicine, Kyoto University.
No Shinkei Geka. 1997 Aug;25(8):733-8.
Cortical venous drainage has been described as one of the major risk factors for dural arteriovenous fistula, which may induce venous hypertension leading to venous ischemia or intracerebral hemorrhage. However, it is rather rare to observe cortical venous drainage manifesting in this way in the cavernous sinus region. We report a case of a 55-year-old gentleman with a right cavernous dural arteriovenous fistula, presenting with conjunctival chemosis, exophthalmus and ocular hypertension on the affected side. Magnetic resonance imaging showed a small intracerebral hemorrhage in the right frontal lobe. Cerebral angiography revealed a dural arteriovenous fistula in the right cavernous sinus draining into the right olfactory vein via the uncal vein, as well as into the superior and inferior ophthalmic veins. This unusual cortical venous reflux was thought to be consistent with the intracerebral hemorrhage found on the magnetic resonance imaging. The patient underwent transvenous embolization for the dural arteriovenous fistula using an inferior petrosal catheterization into the uncal vein was difficult, and the cortical venous reflux through the vein seemed to be slight. However, extravasation of the contrast material occurred in the right frontal lobe after obliteration of the ophthalmic veins during the procedure. The cause of the extravasation was suspected to be the same olfactory vein that had been involved in the previous intracerebral hemorrhage. The obliteration of the dural fistula was continued rapidly, and the fistula disappeared after the embolization. Neurologically, the patient had no noticeable troubles, except for a mild headache. The pretreatment symptoms were alleviated within several days, and the patient was discharged in a week. We emphasize the following points from this rare case in order to facilitate a safer procedure during transvenous embolization for cavernous dural arteriovenous fistula. It is important to obliterate the cortical venous drainage as early as possible, even if the reflux is small or the catheterization is difficult. Repeated, careful sinography is useful for the evaluation of the drainage pattern at certain stages during the transvenous embolization procedure.
皮质静脉引流被认为是硬脑膜动静脉瘘的主要危险因素之一，可导致静脉高压，进而引起静脉缺血或脑出血。然而，在海绵窦区域以这种方式表现出皮质静脉引流的情况相当罕见。我们报告一例55岁男性患者，患有右侧海绵窦硬脑膜动静脉瘘，表现为患侧结膜水肿、眼球突出和眼压升高。磁共振成像显示右侧额叶有少量脑出血。脑血管造影显示右侧海绵窦硬脑膜动静脉瘘通过钩静脉引流至右侧嗅静脉，并引流至上、下眼静脉。这种不寻常的皮质静脉回流被认为与磁共振成像上发现的脑出血一致。患者接受了经静脉栓塞治疗硬脑膜动静脉瘘，使用岩下窦插管进入钩静脉困难，且通过该静脉的皮质静脉回流似乎很轻微。然而，在手术过程中眼静脉闭塞后，右侧额叶出现了造影剂外渗。外渗的原因怀疑是与之前脑出血相关的同一嗅静脉。硬脑膜瘘的闭塞迅速继续进行，栓塞后瘘消失。神经方面，除了轻度头痛外，患者没有明显不适。治疗前的症状在几天内得到缓解，患者在一周后出院。我们从这个罕见病例中强调以下几点，以便在经静脉栓塞海绵窦硬脑膜动静脉瘘时进行更安全的手术。尽早闭塞皮质静脉引流很重要，即使回流较小或插管困难。在经静脉栓塞手术的某些阶段，反复、仔细的窦道造影有助于评估引流模式。
