- Department of Neurosurgery, National Center for Global Health and Medicine, Gunma, Japan
- Department of Radiology, National Center for Global Health and Medicine, Gunma, Japan
- Department of Neurosurgery, Gunma University, Gunma, Japan
Department of Radiology, National Center for Global Health and Medicine, Gunma, Japan
DOI:10.4103/2152-7806.96076Copyright: © 2012 Miyagishima T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Miyagishima T, Hara T, Inoue M, Terano N, Ohno H, Okamoto K, Hasuo K. Pontine venous congestion due to dural arteriovenous fistula of the cavernous sinus: Case report and review of the literature. Surg Neurol Int 14-May-2012;3:53
How to cite this URL: Miyagishima T, Hara T, Inoue M, Terano N, Ohno H, Okamoto K, Hasuo K. Pontine venous congestion due to dural arteriovenous fistula of the cavernous sinus: Case report and review of the literature. Surg Neurol Int 14-May-2012;3:53. Available from: http://sni.wpengine.com/surgicalint_articles/pontine-venous-congestion-due-to-dural-arteriovenous-fistula-of-the-cavernous-sinus-case-report-and-review-of-the-literature/
Background:We report herein a case of cavernous sinus (CS)-dural arteriovenous fistula (DAVF) with brainstem venous congestion that was successfully treated by transarterial embolization, followed by radiotherapy.
Case Description:An 80-year-old woman presented with right eye chemosis and left hemiparesis. T2-weighted magnetic resonance imaging showed hyperintensity of the pons. Diagnostic cerebral angiography demonstrated CS-DAVF draining into the right superior orbital vein and petrosal vein, and fed by bilateral internal and external carotid arteries. Transarterial embolization was performed and followed by radiotherapy, resulting in resolution of the pontine lesion and neurological and ophthalmological symptoms within 5 months.
Conclusions:We also review the literature regarding therapy for CS-DAVF with brainstem venous congestion. Once CS-DAVF with venous congestion of the brainstem has been definitively diagnosed, immediate therapy is warranted. Treatment with transarterial embolization followed by radiation may be an important option for elderly patients when transvenous or transarterial embolization is not an option.
Keywords: Cavernous dural arteriovenous fistula, pontine venous congestion, radiation therapy, transarterial embolization
Pontine venous congestion is a rare but serious complication of cavernous sinus (CS)-dural arteriovenous fistula (DAVF). Although the number of reports on CS-DAVF with brainstem venous congestion has been increasing in recent years,[
The patient was an 80-year-old woman with no past history of head injury, sinus thrombosis, or infections. She initially noticed redness of the sclera in the right eye and consulted a local ophthalmologist. Three months later, she was referred to our hospital. The right eye showed chemosis and swelling of the eyelid. Head computed tomography (CT) revealed exophthalmos and swelling of the right superior orbital vein (SOV). She was initially followed on an outpatient basis. One month later, symptoms including chemosis, facial swelling, and gait disturbance were found to be worsening and she was admitted to our hospital.
Neurological examination showed mild ataxia of the left lower extremity and dysarthria. A full range of eye movement was seen, and the patient did not complain of diplopia.
T2-weighted magnetic resonance (MR) imaging showed a hyperintense lesion on the right side of the upper pons and the right SOV was dilated [
Cerebral angiography showed CS-DAVF supplied by the dural branches of bilateral internal and external carotid arteries, draining into the right SOV and petrosal vein [
Because superselective catheterization through the petrosal sinus up to the pathologic shunt points was not successful, transvenous embolization was technically difficult. And then the TAE was attempted. We used polyvinyl alcohol (PVA) particles of 250–420 μm as embolic material and embolized bilateral accessory meningeal arteries. Radiotherapy was performed 2 weeks after TAE. Total dose was 34 Gy delivered in 17 fractions. These techniques have been described in detail previously.[
Eyelid swelling resolved within a few days after TAE and gait disturbance had not deteriorated by discharge. Follow-up MR imaging about 5 months after therapy showed resolution of brainstem edema and swelling, leaving a lacuna in the right side of the pons [
Brainstem venous congestion may develop in patients with DAVF of the posterior fossa.[
In the clinical diagnosis and treatment of common DAVF, patterns of venous drainage need to be considered.[
Many treatment options have been presented for DAVF.[
Once CS-DAVF with venous congestion of the brainstem has been definitively diagnosed, immediate therapy is warranted. Treatment with TAE followed by radiation may be an important option for elderly patients when transvenous or transarterial embolization is not an option.
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