Ａｇｇｒｅｓｓｉｖｅ Ｄｕｒａｌ Ａｒｔｅｒｉｏｖｅｎｏｕｓ Ｆｉｓｔｕｌａの血行動態と治療

Abstract

We retrospectively analyzed the hemodynamic status and treatment results of aggressive intracranial dural arteriovenous fistulas (dAVFs) that presented with intracranial hemorrhage, cerebral infarction, status epilepticus, and symptoms of increased intracranial pressure (ICP). Out of 114 dAVFs we experienced since 1991, 31 were aggressive lesions. Eighteen cases presented with an intracranial hemorrhage, 4 with venous infarction, 3 with status epilepticus, and 6 with symptoms of increased ICP. We retrospectively analyzed the hemodynamic status (focusing on the retrograde leptomeningeal venous, and retrograde sinus drainage) and treatment results of these 31 cases. [cavernous sinus dAVF] Of 52 cases, retrograde leptomeningeal venous drainage (RLVD) was observed in 8, and 2 of these 8 cases presented with an intracerebral hematoma. One was successfully treated by surgical transvenous embolization, and the other by percutaneous transvenous embolization. [superior sagittal, transverse-sigmoid, and marginal sinus dAVF] Of 44 cases, RLVD was observed in 24 and retrograde sinus drainage in 3. Nineteen of these 27 cases presented with an aggressive pattern, including intracerebral hematoma in 8, venous infarction in 2, status epilepticus in 3, and increased ICP symptoms in 6. Eight of these 19 cases were treated only by endovascular procedures, 9 by surgical transvenous embolization, 2 by transarterial embolization combined with operation. [others] The location of dAVF in other cases was the cranial vault in 2 cases, anterior cranial base in 6, craniocervical junction in 7, and tentorium in 3. RLVD was seen in all of these 18 cases, and 10 presented with an aggressive course, including intracerebral hematoma in 8 and venous infarction in 2. Four cases were treated by transarterial embolization, and 6 by operation. Complete angiographic obliteration after treatment was obtained in 24 (77%) cases. The Glasgow Outcome Scale was GR in 18 cases, MD in 4, SD in 4, VS in 4, and D in 1. Procedure-related complications occurred in 2 cases. Aggressive lesions accounted for 2% of cavernous sinus, 43% of transverse-sigmoid & superior sagittal sinuses, and 55% of the other sinus or cortical dural AVFs. Impaired cerebral venous return due to RLVD was a main cause of the aggressive behaviors. Combined endovascular and surgical treatment was very effective for those lesions.