- Department of Neurosurgery, Japan Organization of Occupational Health and Safety Toyama Rousai Hospital, Toyama, Japan.
DOI:10.25259/SNI_571_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Yu Shimizu, Kazuhiko Tokuda, Cheho Park. Sphenoid wing dural arteriovenous fistula: A case report and literature review. 16-Dec-2020;11:438
How to cite this URL: Yu Shimizu, Kazuhiko Tokuda, Cheho Park. Sphenoid wing dural arteriovenous fistula: A case report and literature review. 16-Dec-2020;11:438. Available from: https://surgicalneurologyint.com/surgicalint-articles/10463/
Background: Sphenoid wing dural arteriovenous fistula (SWDAVF) is rare that is typically fed by middle meningeal artery feeders and that drain through the sphenoparietal sinus or middle cerebral vein. Here, we report a case of SWDAVF treated by coils placed in the venous aneurysm through the contralateral cavernous sinus (CS).
Case Description: A 37-year-old woman was admitted to our hospital with headache and bilateral oculomotor nerve palsy. Magnetic resonance images and an angiogram showed a venous aneurysm in the right middle cranial fossa. A DAVF, consisting of two main feeders, was diagnosed based on the angiogram findings. The fistula drained into the left inferior petrosal sinus (IPS) through the left CS and right IPS. Given the remarkable extent of venous ectasia together with the headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right IPS was not feasible, as it is strenuous to insert the microcatheter into the right IPS. Thus, we tried an approach through the left IPS. The venous aneurysm was embolized with coils. The postoperative course was uneventful, and postoperative cerebral angiography confirmed disappearance of the fistula.
Conclusion: A SWDAVF is extremely rare. In our case, since the AVF drained into the contralateral CS, contralateral ocular symptoms occurred. Endovascular occlusion of the venous aneurysm and fistula was achieved through a transvenous approach.
Keywords: Cavernous sinus, Dural arteriovenous fistula, Endovascular, Venous aneurysm
Intracranial dural arteriovenous fistula (DAVF) is sporadic, pathologic arteriovenous connections that most commonly involve the wall of a major dural venous sinus.[
A 37-year-old woman presented with headache, bilateral ptosis, and right proptosis. She denied a history of head trauma and hypertension, and her medical history was unremarkable. Her laboratory data were all normal. Physical examination revealed bilateral oculomotor nerve palsy. Magnetic resonance (MR) imaging demonstrated varix in the right middle cranial fossa [
(a and b) Right external carotid artery injection, frontal view. A large venous varix rapidly fills with early drainage into the superior orbital vein, left cavernous sinus, and inferior petrosal sinus. The feeding of the dural arteriovenous fistula (DAVF) through the middle meningeal artery is observed. (c) Superselective catheterization of the middle meningeal artery (MMA) shows feeding of the DAVF through the petrosal branch of the MMA.
Our approach was through the left IPS since the right IPS was occluded. A 6 Fr FUBUKI (ASAHI INTECC, Nagoya, Japan) guiding catheter was placed in the left internal jugular vein. A 4.2 Fr FUBUKI distal access catheter (ASAHI INTECC, Nagoya, Japan) was introduced through the left IPS and then placed in the right CS at the orifice of the sphenoparietal sinus. Excelsior SL-10STR (Stryker, Kalamazoo, MI, USA) and ASAHI CHIKAI (ASAHI INTECC, Nagoya, Japan) were advanced into the venous aneurysm of the SWL. Following the introduction of the microcatheter into the SWL, superselective angiography suggested a high-flow, multichannel fistula between the right petrosal branch of the MMA and a venous aneurysm wall [
DAVF within the greater and lesser sphenoid wings has vascular features distinctive from the CS.[
The treatment options for SWDAVF have been described in previous reports and include TAE, TVE, and surgical obliteration. However, TVE is the primary therapeutic strategy for the curative treatment of DAVF. If it is impossible to approach the affected sinus through the IPS, it is necessary to consider another venous access route, such as the facial vein or the vein of Galen.[
We summarized the clinical data of SWDAVF [
Shi et al. reported two cases treated by successful endovascular treatment.[
Endovascular treatment has been favored because the draining vein just proximal to the fistula point at the lesser sphenoid wing is easy to access through the IPS and CS. Six patients underwent endovascular treatment only, four patients underwent surgery only, and five underwent both [
Although arterial embolization for SWDAVF has only been performed to reduce the risk of the surgical approach, successful endovascular occlusion for SWDAVF has been reported recently.[
Here, we report the rare patient of SWDAVF presenting with ocular symptoms. TVE was performed, and the patient had a favorable outcome. To the best of our knowledge, this is the first report of a patient presenting with bilateral ocular symptoms due to SWDAVF with progressive bilateral ocular symptoms related to cranial nerve compression is warranted surgical intervention.
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