The Neuroradiology Journal 21: 428-432, 2008
www. centauro. it
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis A Case Report XIANLI LV, JINGBO ZHANG, YOUXIANG LI, CHUAN JIANG, ZHONGXUE WU Beijing Neurosurgical institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China
Key words: dural arteriovenous fistula, transverse sigmoid sinus
SUMMARY – Dural arteriovenous fistulas (DAVFs) not directly shunting into the cavernous sinus are a rare cause of chemosis. An unusual case of a transverse sigmoid sinus DAVF associated with chemosis related to high intravenous pressure is presented. A 39-year-old man presented with a two year history of left chemosis. Ocular examination disclosed left episcleral and retinal venous congestion, and optic disc paleness. Visual acuity and visual field were normal. Angiography revealed a DAVF supplied by a branch arising from the left postauricular artery, the left middle meningeal artery and the left occipital artery, which drained into the vein of Trolard into the superior sagittal sinus and the sphenoparietal sinus via the mild dilated vein of Labbé. Endovascular treatment was performed by transarterial embolization with Onyx-18, which resulted in occlusion of the fistula and complete clinical cure confirmed at discharge. Chemosis may be caused by an arteriovenous lesion remote from the optic organ as a result of rerouting venous drainage promoting the intracavernous pressure. Transarterial embolization of a DAVF may result in complete cure if advantageous arterial anatomy allows for flow control and occlusion of the fistulous connection with liquid nonadhesives. Introduction Transverse-sigmoid sinus dural arteriovenous fistula (TSDAVF) can present with diverse clinical symptoms such as pulsatile tinnitus, seizures, visual disturbances, dementia and intracranial hemorrhage 4,5,8,10. Brain stem infarction has also been reported 9. We present a case of a TSDAVF with venous reflux into the superior sagittal sinus and the left sphenoparietal sinus via the vein of Labbé and the vein of Trolard. This led to the unusual presentation of chemosis related to retrograde venous drainage, which, to our knowledge, has only been reported in one previous case. Case Report A 39-year-old man with diabetes presented with two year history of left chemosis without visual disturbances or pulsatile tinnitus. He 428
had no history of head trauma, intracranial infection, sinus thrombosis or brain surgery. His ophthalmic examination revealed normal visual acuity, left episcleral venous congestion and normal motility. Ophthalmoscopy disclosed left congested venous vessels and no papilledema. Visual field was normal. Cerebral angiography revealed a DAVF fed by the left middle meningeal artery (MMA), left postauricular artery and left occipital artery. The fistulous connection was located at the junction of the left transverse sinus and sigmoid sinus, draining directly into the cortical vein of Labbé. The left transverse and sigmoid sinuses were not opacified in the left carotid angiograms, indicating absence or thrombotic occlusion. Therefore, the drainage of the arteriovenous shunt was rerouted via the Labbé and Trolard veins which drained into the superior sagittal sinus with reflux into the left cavernous sinus. The transarterial management of the patient was performed as follows. The left MMA was cathe-
Xianli Lv
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis
Figure 1 Image demonstrating left episcleral venous congestion.
terized with a Marathon microcatheter (M.T.I) and embolized with Onyx-18. When any venous migration or reflux was found, the injection was stopped to allow for solidification, then the injection was continued. The Onyx then filled a different portion of the lesion until control angiograms demonstrated complete occlusion of the fistula by the end of the procedure. This patient was discharged on postprocedure day three. After two days, left episcleral venous congestion remitted. Two months later, the patient was contacted by telephone and his symptoms had completely resolved. Discussion TSDAVF represents a common subgroup comprising approximately 38% of all intracranial DAVFs 1. As in other intracranial DAVFs, the genesis of TSDAVF remains unclear 11. Cerebral angiography in our patient disclosed an absence of the left transverse and sigmoid sinuses. Thrombosis of a dural sinus is observed in most cases, and trauma and surgery also seem to contribute to the formation of TSDAVFs 11. TSDAVFs are located in the transverse sigmoid sinus and are fed primarily from
branches of the MMA, postauricular artery and occipital artery and sometimes from the posterior cerebral artery. Venous drainage varies greatly. It is known that an aggressive neurological course is much more frequently observed in fistulas with leptomeningeal venous drainage, in variceal or aneurysmal venous dilations 1,8-10 . Thus, as a result of their venous drainage, TSDAVFs commonly present with intracranial hemorrhage or progressive neurological deficits 4,5. The TSDAVF in the case presented here caused left episcleral and retinal venous congestion. The blood shunted into a dilated cortical vein of Labbé and anteriorly through the middle cerebral superficial vein, reached the left cavernous sinus and the superior sagittal sinus. Absence of the left transverse and sigmoid sinuses and high venous pressure in the deep venous system can also cause an increase in intracavernous pressure. As a result of the reversed blood flow through the left sphenoparietal sinus, episcleral and retinal venous congestion developed. It can further be assumed that this arterialized flow led to an increased venous pressure and restricted the normal orbital venous drainage: this may explain the patient’s symptoms. As the present case demonstrates, symptoms improve after successful embolization. TSDAVF can be managed with transarterial or transvenous embolization and 429
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis
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The Neuroradiology Journal 21: 428-432, 2008
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Figure 2 A-F Left common carotid angiogram (A) shows the fistula is supplied by the left middle meningeal artery, the left postauricular artery and left occipital artery and drains into the vein of Labbé. B) Venogram of the left common carotid injection showing the venous drainage is the superior sagittal sinus via the Trolard vein (arrowheads) and the left sphenoparietal sinus (arrows). C) Under roadmapping the microcatheter was advanced to the fistula point via the left middle meningeal artery (arrowheads). D) Onyx injection was performed under biplane roadmapping and the injection stopped when venous migration was observed (arrowheads). E) Postembolization angiogram of the left external carotid artery reveals complete embolization of the fistula. F) After embolization, the fluoroscopic image, lateral view, demonstrates the Onyx cast (arrow).
surgery 1,3,4,7,9,10. Successful transvenous coil embolization of TSDAVFs via the internal jugular vein and the sigmoid sinus has been reported 2,3,4,7-9 . However, endovascular tools have improved remarkably during the past ten years, providing highly flexible, hydrophilic coated catheters and wires that allow more distal navigation and permit complete occlusion of a DAVF via the endoarterial route alone 6. This technique may be facilitated by a limited number of feeding vessels an a wedged position allowing injection of liquid nonadhesives (Onyx-18) in a relatively controlled fashion, as reported by Rezenda et Al 6. In our own recent experience, we have successfully treated a number of high-grade DAVFs by means of this technique. We usually chose the middle menin-
geal artery to be catheterized because long reflux was admitted. Moreover, embolization via a transarterial approach that used flow control via a single remaining feeder after occluding all other contributing pedicles seemed to be the best option. Conclusion TSDAVFs remote from the optic organ may cause episcleral venous congestion as a result of rerouting of venous drainage. Transarterial embolization of a TSDAVF is feasible and may result in complete cure if arterial anatomy permits flow control and occlusion of the fistulous connection with Onyx-18. 431
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis
Xianli Lv
References 1 Caragine LP, Halbach VV, Dowd CF et Al: Parallel venous channel as the recipient pouch in transverse/sigmoid sinus dural fistulae. Neurosurgery 53: 1261-1266, 2003. 2 Daniel R, Jean R: The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas. Neurosurgery 40: 1133-1144, 1997. 3 Hanaoka M, Satoh K, Satomi J et Al: Microcatheter pull-up technique in the transvenous embolization of an isolated sinus dural arteriovenous fistula. Technical note. J Neurosurg 104: 974-977, 2006. 4 Irie F, Fujimoto S, Uda K et Al: Primary intraventricular hemorrhage from dural arteriovenous fistula. J Neurol Sci 215: 115-118, 2003. 5 Luo CB, Chang FC, Wu HM et Al: Transcranial embolization of a transverse-sigmoid sinus dural arteriovneous fistula carried out through a decompressive craniectomy. Acta Neurochir 149: 197-200, 2007. 6 Rezende MTS, Poitin M, Mounayer C et Al: Dural arteriovenous fistula of the lesser sphenoid wing region treated with Onyx: technical note. Neuroradiology 48: 130-134, 2006. 7 Rivet DJ, Goddard JK, Rich KM et Al: Percutaneous transvenous embolization of a dural arteriovenous fistula through a mastoid emissary vein. Technical note. J Neurosurg 105: 636-639, 2006. 8 Satoh K, Satomi J, Nakajima N et Al: Cerebellar hemorrhage caused by dural arteriovenous fistula: a review of five cases. J Neurosurg. 94: 422-426, 2001.
432
9 Satoh M, Kuriyama M, Fujiwara T et Al: Brain stem ischemia from intracranial dural arteriovenous fistula: case report. Surg Neurol 64: 341-345, 2005. 10 Saurabh BS, Anil KL, Christopher FD: Transverse/sigmoid sinus dural arteriovenous fistulas presenting as pulsatile tinnitus. Laryngoscope 109: 54-58, 1999 11 Tomio S, Katsumi H, Kazunori K et Al: Postsurgical development of dural arteriovenous malformations after transpetrosal and transtentorial operations: case report. Neurosurgery 37: 820-825, 1995.
Chuhan Jiang, MD Beijing Neurosurgical Institute Beijing Tiantan Hospital Capital Medical University 6,Tiantan Xili Beijing, Heibei 100050 China Tel.: 86-10-67098850 E-mail: [email protected]
www. centauro. it
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis A Case Report XIANLI LV, JINGBO ZHANG, YOUXIANG LI, CHUAN JIANG, ZHONGXUE WU Beijing Neurosurgical institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China
Key words: dural arteriovenous fistula, transverse sigmoid sinus
SUMMARY – Dural arteriovenous fistulas (DAVFs) not directly shunting into the cavernous sinus are a rare cause of chemosis. An unusual case of a transverse sigmoid sinus DAVF associated with chemosis related to high intravenous pressure is presented. A 39-year-old man presented with a two year history of left chemosis. Ocular examination disclosed left episcleral and retinal venous congestion, and optic disc paleness. Visual acuity and visual field were normal. Angiography revealed a DAVF supplied by a branch arising from the left postauricular artery, the left middle meningeal artery and the left occipital artery, which drained into the vein of Trolard into the superior sagittal sinus and the sphenoparietal sinus via the mild dilated vein of Labbé. Endovascular treatment was performed by transarterial embolization with Onyx-18, which resulted in occlusion of the fistula and complete clinical cure confirmed at discharge. Chemosis may be caused by an arteriovenous lesion remote from the optic organ as a result of rerouting venous drainage promoting the intracavernous pressure. Transarterial embolization of a DAVF may result in complete cure if advantageous arterial anatomy allows for flow control and occlusion of the fistulous connection with liquid nonadhesives. Introduction Transverse-sigmoid sinus dural arteriovenous fistula (TSDAVF) can present with diverse clinical symptoms such as pulsatile tinnitus, seizures, visual disturbances, dementia and intracranial hemorrhage 4,5,8,10. Brain stem infarction has also been reported 9. We present a case of a TSDAVF with venous reflux into the superior sagittal sinus and the left sphenoparietal sinus via the vein of Labbé and the vein of Trolard. This led to the unusual presentation of chemosis related to retrograde venous drainage, which, to our knowledge, has only been reported in one previous case. Case Report A 39-year-old man with diabetes presented with two year history of left chemosis without visual disturbances or pulsatile tinnitus. He 428
had no history of head trauma, intracranial infection, sinus thrombosis or brain surgery. His ophthalmic examination revealed normal visual acuity, left episcleral venous congestion and normal motility. Ophthalmoscopy disclosed left congested venous vessels and no papilledema. Visual field was normal. Cerebral angiography revealed a DAVF fed by the left middle meningeal artery (MMA), left postauricular artery and left occipital artery. The fistulous connection was located at the junction of the left transverse sinus and sigmoid sinus, draining directly into the cortical vein of Labbé. The left transverse and sigmoid sinuses were not opacified in the left carotid angiograms, indicating absence or thrombotic occlusion. Therefore, the drainage of the arteriovenous shunt was rerouted via the Labbé and Trolard veins which drained into the superior sagittal sinus with reflux into the left cavernous sinus. The transarterial management of the patient was performed as follows. The left MMA was cathe-
Xianli Lv
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis
Figure 1 Image demonstrating left episcleral venous congestion.
terized with a Marathon microcatheter (M.T.I) and embolized with Onyx-18. When any venous migration or reflux was found, the injection was stopped to allow for solidification, then the injection was continued. The Onyx then filled a different portion of the lesion until control angiograms demonstrated complete occlusion of the fistula by the end of the procedure. This patient was discharged on postprocedure day three. After two days, left episcleral venous congestion remitted. Two months later, the patient was contacted by telephone and his symptoms had completely resolved. Discussion TSDAVF represents a common subgroup comprising approximately 38% of all intracranial DAVFs 1. As in other intracranial DAVFs, the genesis of TSDAVF remains unclear 11. Cerebral angiography in our patient disclosed an absence of the left transverse and sigmoid sinuses. Thrombosis of a dural sinus is observed in most cases, and trauma and surgery also seem to contribute to the formation of TSDAVFs 11. TSDAVFs are located in the transverse sigmoid sinus and are fed primarily from
branches of the MMA, postauricular artery and occipital artery and sometimes from the posterior cerebral artery. Venous drainage varies greatly. It is known that an aggressive neurological course is much more frequently observed in fistulas with leptomeningeal venous drainage, in variceal or aneurysmal venous dilations 1,8-10 . Thus, as a result of their venous drainage, TSDAVFs commonly present with intracranial hemorrhage or progressive neurological deficits 4,5. The TSDAVF in the case presented here caused left episcleral and retinal venous congestion. The blood shunted into a dilated cortical vein of Labbé and anteriorly through the middle cerebral superficial vein, reached the left cavernous sinus and the superior sagittal sinus. Absence of the left transverse and sigmoid sinuses and high venous pressure in the deep venous system can also cause an increase in intracavernous pressure. As a result of the reversed blood flow through the left sphenoparietal sinus, episcleral and retinal venous congestion developed. It can further be assumed that this arterialized flow led to an increased venous pressure and restricted the normal orbital venous drainage: this may explain the patient’s symptoms. As the present case demonstrates, symptoms improve after successful embolization. TSDAVF can be managed with transarterial or transvenous embolization and 429
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis
A
B
C
D
430
Xianli Lv
www. centauro. it
E
The Neuroradiology Journal 21: 428-432, 2008
F
Figure 2 A-F Left common carotid angiogram (A) shows the fistula is supplied by the left middle meningeal artery, the left postauricular artery and left occipital artery and drains into the vein of Labbé. B) Venogram of the left common carotid injection showing the venous drainage is the superior sagittal sinus via the Trolard vein (arrowheads) and the left sphenoparietal sinus (arrows). C) Under roadmapping the microcatheter was advanced to the fistula point via the left middle meningeal artery (arrowheads). D) Onyx injection was performed under biplane roadmapping and the injection stopped when venous migration was observed (arrowheads). E) Postembolization angiogram of the left external carotid artery reveals complete embolization of the fistula. F) After embolization, the fluoroscopic image, lateral view, demonstrates the Onyx cast (arrow).
surgery 1,3,4,7,9,10. Successful transvenous coil embolization of TSDAVFs via the internal jugular vein and the sigmoid sinus has been reported 2,3,4,7-9 . However, endovascular tools have improved remarkably during the past ten years, providing highly flexible, hydrophilic coated catheters and wires that allow more distal navigation and permit complete occlusion of a DAVF via the endoarterial route alone 6. This technique may be facilitated by a limited number of feeding vessels an a wedged position allowing injection of liquid nonadhesives (Onyx-18) in a relatively controlled fashion, as reported by Rezenda et Al 6. In our own recent experience, we have successfully treated a number of high-grade DAVFs by means of this technique. We usually chose the middle menin-
geal artery to be catheterized because long reflux was admitted. Moreover, embolization via a transarterial approach that used flow control via a single remaining feeder after occluding all other contributing pedicles seemed to be the best option. Conclusion TSDAVFs remote from the optic organ may cause episcleral venous congestion as a result of rerouting of venous drainage. Transarterial embolization of a TSDAVF is feasible and may result in complete cure if arterial anatomy permits flow control and occlusion of the fistulous connection with Onyx-18. 431
Dural Arteriovenous Fistula Involving the Transverse Sigmoid Sinus Presenting as Chemosis
Xianli Lv
References 1 Caragine LP, Halbach VV, Dowd CF et Al: Parallel venous channel as the recipient pouch in transverse/sigmoid sinus dural fistulae. Neurosurgery 53: 1261-1266, 2003. 2 Daniel R, Jean R: The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas. Neurosurgery 40: 1133-1144, 1997. 3 Hanaoka M, Satoh K, Satomi J et Al: Microcatheter pull-up technique in the transvenous embolization of an isolated sinus dural arteriovenous fistula. Technical note. J Neurosurg 104: 974-977, 2006. 4 Irie F, Fujimoto S, Uda K et Al: Primary intraventricular hemorrhage from dural arteriovenous fistula. J Neurol Sci 215: 115-118, 2003. 5 Luo CB, Chang FC, Wu HM et Al: Transcranial embolization of a transverse-sigmoid sinus dural arteriovneous fistula carried out through a decompressive craniectomy. Acta Neurochir 149: 197-200, 2007. 6 Rezende MTS, Poitin M, Mounayer C et Al: Dural arteriovenous fistula of the lesser sphenoid wing region treated with Onyx: technical note. Neuroradiology 48: 130-134, 2006. 7 Rivet DJ, Goddard JK, Rich KM et Al: Percutaneous transvenous embolization of a dural arteriovenous fistula through a mastoid emissary vein. Technical note. J Neurosurg 105: 636-639, 2006. 8 Satoh K, Satomi J, Nakajima N et Al: Cerebellar hemorrhage caused by dural arteriovenous fistula: a review of five cases. J Neurosurg. 94: 422-426, 2001.
432
9 Satoh M, Kuriyama M, Fujiwara T et Al: Brain stem ischemia from intracranial dural arteriovenous fistula: case report. Surg Neurol 64: 341-345, 2005. 10 Saurabh BS, Anil KL, Christopher FD: Transverse/sigmoid sinus dural arteriovenous fistulas presenting as pulsatile tinnitus. Laryngoscope 109: 54-58, 1999 11 Tomio S, Katsumi H, Kazunori K et Al: Postsurgical development of dural arteriovenous malformations after transpetrosal and transtentorial operations: case report. Neurosurgery 37: 820-825, 1995.
Chuhan Jiang, MD Beijing Neurosurgical Institute Beijing Tiantan Hospital Capital Medical University 6,Tiantan Xili Beijing, Heibei 100050 China Tel.: 86-10-67098850 E-mail: [email protected]
