Spontaneous arteriovenous fistula between dural branches of the internal maxillary artery and the posterior cavernous sinus.

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SPONTANEOUS arteriovenous communications between the dural branches of the external carotid artery and the cavernous sinus are rare. Such malformations may be associated with cranial bruit, proptosis, conjunctival swelling, and dilated arterialized conjunctival veins. These signs and symptoms are clinically indistinguishable from those of the more common fistula between the internal carotid artery and the cavernous sinus. The differential diagnosis, therefore, depends upon neuroradiologic studies that include selective angiograms of the internal and external carotid systems. An anomalous arteriovenous communication between branches of the internal maxillary artery and the dural veins entering the posterior cavernous sinus is exemplified in the following report. Case Report A 62-year-old woman with systemic hypertension was referred to the University of California Medical Center (San Francisco) in April 1967 with symptoms of painless and progressive proptosis of the right eye, swelling of the right eyelids, and a noise in her head that had been present for two weeks. One year previously she had experienced the sudden onset of horizontal diplopia, the result of a right abducens palsy. Medical examinations and skull roentgenograms did not reveal the cause of the palsy, which, in the months that followed, regressed slowly. In 1962, five years before occurrence of the proptosis, the patient experienced a spontaneous intraocular hemorrhage, attributed to rupture of one of a group of small microaneurysms located in the periphery of the left retina. On examination the patient was alert and, with the exception of marked proptosis of the right eye, appeared healthy. The blood pressure was 200/110. Exophthalmometer readings were 24 mm on the right and 20 mm on the left. The conjunctiva of the right eye contained many bright red, dilated veins (Fig. 1). Moderately dilated veins and a few punctate retinal hemorrhages were seen in the right fundus. Vision in the involved eye was 20/40 and in the left eye 20/20. The right lateral rectus muscle was partially paretic, but other ocular movements were normal. A loud high-pitched systolic bruit was heard over the right eye, temple, and forehead. Digital compression of either carotid artery did not obliterate the bruit. Routine hematologic studies, including tests of blood coagulation, glucose tolerance, and erythrocyte sedimentation, gave normal results. An electrocardiogram showed evidence of a mild left ventricular conduction defect. Neuroradiologic studies are illustrated in Figures 2 and 3. Neurosurgical treatment was not recommended because of the mild symptoms and the technical problems imposed by the multiplicity of the arteries supplying the arteriovenous malformation. Discussion