Dural Arteriovenous Fistula of the Cavernous Sinus Presenting with Progressive Venous Congestion of the Pons and Cerebrum: Report of one case

Transcription

1 Dural Arteriovenous Fistula of the Cavernous Sinus Presenting with Progressive Venous Congestion of the Pons and Cerebrum: Report of one case Soo-Bin Yim, M.D., Jong-Sung Kim, M.D., Yang Kwon,M.D.*, Choong-Gon Choi, M.D. Department of Neurology, Department of Neurosurgery* & Department of Diagnostic Radiology, University of Ulsan college of Medicine, Asan Medical Center A 61-year-old woman with a left cavernous sinus dural arteriovenous fistula presented with left 6th nerve palsy. Initial brain MRI showed findings consistent with left-sided pontine infarction. Follow-up MRIs revealed an enlarged pontine lesion, and additional lesions in the right hippocampus, both basal ganglia and centrum semiovale mimicking a brain tumor or a demyelinating disease. We suggest that the MRI lesions are venous congestions caused by the shunting of blood flow from the left carotid artery into the venous system. J Korean Neurol Assoc 19(5):520~525, 2001 Key Words : Dural arteriovenous fistula of the cavernous sinus, Venous congestion or Brainstem edema, Angiography Jong-Sung Kim, M.D. 520 Copyright 2001 by the Korean Neurological Association

2 Figure 1. A 61-year-old woman presented with a left abduction deficit with left horizontal gaze and mild proptosis, chemosis, and arterialization of conjunctival vessels. J Korean Neurol Assoc / Volume 19 / September,

3 A1 A2 A3 A4 A5 B1 B2 B3 C1 C2 Figure 2. This angiography shows a DAVF of the cavernous sinus of the patient with progressive venous congestion of the pons and cerebrum. A. The right internal and external carotid angiogram. A 1. Lateral view of the internal carotid angiogram shows that this DAVF is fed by the internal carotid artery (arrowhead). A 2. Lateral view shows that venous drainage is via the superior ophthalmic vein (paired arrowheads). A3. Lateral view shows that the other venous drainage of a DAVF flows through cerebral cortical vein (arrowhead). This view explains hyperintense lesions (Fig. 3) in bilateral centrum semiovale as cerebral venous congestion. A4,5. Anteroposterior and lateral views of the external carotid angiogram shows that this DAVF is fed by many fine and toutuous vessels from some branches of the external carotid artery (arrowhead) and drained into superior ophthalmic vein (paired arrowheads). B. The left internal and external carotid angiogram. B 1, 2. The internal carotid angiogram, lateral view, shows that this DAVF is fed by the internal carotid artery (arrowhead) and drained though the superior ophthalmic vein (paired arrowheads). B3. The external carotid angiogram, lateral view, shows that this DAVF is fed by many fine and toutuous vessels from some branches of the external carotid artery (arrowhead) and drained into superior ophthalmic vein (paired arrowheads). C. Anteroposterior views of the left internal carotid angiogram C 1, 2. This angiogram shows that the venous drainage is through the right inferior petrosal sinus (paired arrowheads). Non-visualization of a left inferior petrosal sinus due to probably thrombosed obliteration explains hyperintense lesion in the pons as pontine venous congestion. 522 J Korean Neurol Assoc / Volume 19 / September, 2001

4 A B C1 C2 C3 C4 Figure 3. A serial MR imaging. A. Initial axial noncontrast T2-weighted MR image shows hyperintensity on the left side of the pons (arrowhead) appearing a pontine infarct. B. One month before admission (2 months later), follow-up axial noncontrast T2-weighted MR image shows significant aggravation of the pontine lesion (arrowhead). C. One week before admission, follow-up MR imaging. C1. Axial noncontrast T2-weighted MR image demonstrates diffuse hyperintensity of the pons (arrowhead). C 2 ~ 5. A contrast-enhanced axial T1-weighted MR images demonstrate marked enhancement of the pons (arrowhead), right hippocampus (paired arrowheads) and bilateral centrum semiovale (two arrowheads) mimicking tumor, stroke or demyelinating disease such as Bechet s disease or multiple sclerosis. C5 J Korean Neurol Assoc / Volume 19 / September,

5 11. Newton TH, Hoyt WF. Dural arteriovenous shunts in the region of the cavernous sinus. N e u r o r a d i o l o g y 1970 ; 1 : Shintani S, Tsuruoka S, Shiigai T. Carotid-cavernous fistula with brainstem congestion mimicking tumor on MRI. Neurology 2000;55: Uchino A, Kato A, Kuroda Y, Shimokawa Y, Kudo S. Pontine venous congestion caused by dural carotid-cavernous fistula. report of two cases. Eur Radiol 1997;7: Teng MMH, Chang T, Pan DHC, Chang CN, Huang CI, Guo WY et al. Brainstem edema: An ususal complication of carotid cavernous fistula. AJNR 1991;12: Halbach VV, Higashida RT, Hieshima GB, Reicher M, Norman D, Newton TH. Dural fistula involving the cavernous sinus: Results of treatment in 30 patients. Radiology 1987;163: Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of sponta- neous carotid-cavernous sinus fistulas. J Neurosurg 1985;62: Debrun GM, Vinuela F, Fox AJ, Davis KR, Ahn HS. Indication for treatment and classification of 132 carotidcavernous fistulas. Neurosurgery 1988;22: J Korean Neurol Assoc / Volume 19 / September, 2001

6 18. Hasuo.K, Mizushima.A, Matsumoto.S, Uchino.A, Uehara.M, Miyoshi F et al. Type D dural carotid-cavernous fistula: Results of combined treatment with irradiation and particulate embolization. Acta Radiologica ; 3 7 : Probst EN, Christante L, Zeumer H. Brain-stem venous congestion due to a dural arteriovenous fistula in the posterior fossa. J Neurol : Takahashi S, Tomura N, Watarai J, Mizoi K, Manabe H. Dural arteriovenous fistula of the cavernous sinus with venous congestion of the brain stem: Report of two cases. AJNR 1999;20: Halbach VV, Higashida RT, Hieshima GB, Hardin CW. Transvenous embolization of dural fistulas involving the carvenous sinus. AJNR 1989;10: Ishikawa M, Handa H, Taki W, Yoneda S. Management of spontaneous carotid-cavernous fistulae. Surg. Neurol 1982;18: Bitoh S, Hasegawa H, Fujiwara M, Nakao K. Irradiation of spontaneous carotid-cavernous fistula. Surg. Neurol 1982;17: Voigt K, Sauer M, Dichgans J. Spontaneous occlusion of a bilateral caroticocavernous fistula studied by serial angiography. Neuroradiology 1971;2: J Korean Neurol Assoc / Volume 19 / September,