HANDA, JYOJI

KIDOOKA, MINORU

NAKASU, SATOSHI

NAKASU, YOKO

Kyoto University Research Information Repository

TitleDural Arteriovenous Malformation in the Anterior CranialFossa : Report of a Case.Author(s)KIDOOKA, MINORU; NAKASU, SATOSHI; NAKASU,YOKO; HANDA, JYOJICitation日本外科宝函 (1982), 51(6): 1040-1046Issue Date1982-11-01URL http://hdl.handle.net/2433/208977RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityArch Jpn Chir 51(6), 1040～1046‘：＼ov., 1982 Dural Arteriovenous Malformation in the Anterior Cranial Fossa: Report of a Case. ¥[1:-;0RU KIDりOKA、SATOSHINAKASU, YOKO NAKASl', JYOJI HANDA Department of Keurosurgery, Shiga University of ¥!edical Science (Director: Prof. Dr. Jyoji Han<la) Received for Publication, Aug. 27, 1982. Dural art正吋ovenousmalformations (A VMs) are not rare, comprising 10 to 15% of al intracranial A Y:¥l札 However,most of dural A VJ¥T s have been seen in the region of the trans-verse sigmoid sinus, or of the cavernous sinus噌 andthe reports of dural A V;¥I s involving the anterior cranial fossa are rare. Case Report This 56-year-old man was admitted with a history of double vision of 1 month’s duration. He had been healthy until 1 month prior to admission when he suddenly experienced severe frontal headaches. トサ10rtlyafterwards he lost consciousness and remained unresponsive for a few hours. Although he apparently did not fal, nor hit his face or head at that time, his wife noticed that his right eyelids markedly swelled. When the swelling subsided a few days later, his right upper eyelid W<l" drooping, and the double vision was apparent when he raised his ptotic lid with finger,. On admission‘physical and neurological examinations were normal except for a right third nerve palsy. :¥either cervical nor cranial bruit waぉheard,and the results of routine laborator)' examinations were al within normal limits. Computed tomographic (CT) scan was performed 4 weeks after the clinical onset. It showed a low density area in the basal portion of the right frontal lobe. Jn the upper日！icesa thin ex tracerebral collection with mixed iso and low densities was present over the right frontal con-vexity, and the frontal horns were minimally displaced toward the left. An intravenous administration of iodinated contrast media demonstrated a bi-lobed abnormal enhancement in the tip of the frontal ba同司 fromwhich a curvilinear enhancement continued toward the presellar region (Fig. 1). Bilattγal、electiveinternal and external carotid angiography revealed a clural A Y¥l in the tip of the frontal l川町 The feeding arteries were the anterior ethmoidal artery on each ,ide as well出 theinternal maxillary, middle meningeal and superficial temporal arteries on the right side. The draining vein entered the superior sagittal sinus and the right cavernous sinus. On Key wordち・ Anterior cranial fosa, Dural A Vl¥l‘Oculomotor nerve, Vascular malformation. 索引語－前頭蓋禽，硬膜動静胞奇形，動限「1¥1’F，血管障害，（？Present address: Jyoji I-Ianda, ¥!. D., Department of N!'urn、ur宮町y,Shi宮丸 Uni、crsityof ¥lcdical山icn・ Sl'l;i Ohtsu，同higaken 520・21, Japan. DL・RALARTERIO¥'E>JOl. 討 :¥IALI・りIOIATIONFig. 1. Noncontrast (A句 Bland contrast (C. [) CT. Large arrow indicates an aneurysmal dilatation of the draining vein, and "hite arrows the draining ¥'ein. 1041 the right side, the initial portion of the draining vein showed an anぞUf¥＇川1aldilatation (Fig. 2). Orbital phlebography via the frontal vein showed a non-visualization of the S III portion of the right superior ophthalmic vein. The right cavernous sinus u川 poorlycontrast-filled. At operation, a right frontal bone flap was turned laterally. On elevating the right frontal lobe and incising the falx cerebri, an A Vl¥J was found to involve the tip of the frontobasal dura mater on both sides. The dura mater covering theぐristagalli looked intact. On the left side‘a draining vein entered the cortical vein that coursed posteriorly. On the right side. a large red vein was found to arise from the center of the AVi¥I After traversing the subdural只pa「e.this 1042 日外宝第51巻第6号（昭和57年11月）事 二’) 、． Al B D Fi邑.2. Right internal carotid (A, B), left internal carotid (C), and right external carotid (D) angiograms. a: dural A＼＇：＼！.。： enlargedophthalmic arteη，d: draining vein, arrow: aneuηI・ smal dilatation of the draining vein vein entered the ancurysmal saτthat was mostly embedded in the parenchyma of the frontal tip. From this aneurysmal sac arose two veins; the one coursed superiorly over the convexity surface to enter the superior sagittal sinus and the other coursed posteriorly on the basal surface of the right frontal lor.附 Thisaneurysmal dilatation of the draining vein was surrounded by a small amount of aged, amorphous intracerebral clot, which had ruptured into the subdural space to form a thin organizing clot. The hematoma was evacuated, and the dural A VM was totally removed by peeling it off from the bone of the skull base、togetherwith the narrow fringe of the surrounding. seemingly normal basal dura mater. Arterial bleeding from the foramen caecum and the ethmoid plate on each side wa日readilycontrolled using the bone wax and a monopolar coagulation. Postoperatively the added neurologic deficit was confined to anosmia on the right side. DURAL ARTERIOVENOl'S :¥IALFORMATION 1043 Follow-up bilateral angiography confirmed a total removal of the lesion. The oculomotor palsy disappeared completely within three months. Discussion Dural A Vl¥ls occur most often in the region of the transvers巴－sigmoidsinus. There is no sex differences in such cases、andthe age of presentation is predominantly between 40 and 60 ye:us. Besides annoying tinnitus andぞranialbruit, the symptoms and signメsecondaryto an increased intracranial venous pressure and cerebral hypoxia, such as headaches, papilledema and various neurologic deficits, are often seen in patients harboring a large arteriovenous五stulain this region. The incidence of association of intracranial hemorrhage, however, isrelatively low1,1,s1. Dural A VMs in the region of the cavernous sinus probably account for most of the >o called spontaneous carotid-cavernous sinus fistulae. This vascular anomaly is most often seen in the middle-aged woman. The signs and symptoms are usually mild and include dilatation of conjunctival veins, bruit, and proptosis. Transient abducent paresis and unilateral headaches may be seen, but the intracranial hemorrhage has not been reported and the spontaneous resolu tron rs not uncommoni.r.1. In comparison, dural A VMs involving the anterior cranial fossa ar巴veryrare. Pertinent clinical data of 8 such cases including the one herein reported are summarized in the Table 12,3,4,5,9,101. The ag巴ofthe patients ranged from 34 to 61 years司 and7 patients were male and one was female. Cranial bruit was heard in only 2 cases. Dural A Yl¥Is in the anterior cranial fossa are further divided into three groups: those involv-ing primarily the basal dura mater of the anterior cranial fossa, the anterior portion of the falx cerebri, and the dura mater of the frontal convexity10>. Their principal blood supply is the ophthalmic artery, via the anterior or posterior ethmoidal branch and/or anterior falx arteη7 The middle meningeal artery and the superficial temporal artery, and rarely a small branch of the pial artery also may feed the malformation. '.¥lost A Y:¥ls in this location drain into the cortical vein, but the inferior sagittal sinus or the cavernous sinus may be involved. Present case is unique in that the lesions occurred symmetrically on both sides. The most striking point with this type of dural A V'.¥ls is that the complicating intracranial hemorrhage occurred in five out of 8 patients. Two patients experienced subarachnoid hemor-rhage, and three other patients had intracerebral hemorrhage. Putaminal hemorrhage was found in the other one patient礼 butit was not related to his dural A V¥l located in the tip of the left frontal base. The origin of complicating intracranial hemorrhage j, believed to be the draining vein rather than the nidus of the AV＼！‘ and this was the case in the present patient. It seems interesting to note here that the aneurysmal dilatation of the draining vein was seen in 4 out of 5 patients with adequate description in the reports. Such an aneurysmal sac interposed between the nidus of the AV'.¥! and the cortical vein or it was embedded in the brain. In our patient, the aneurysmal sac was embedded in the brain and it was surrounded by a localized clot. HouSER et al. also re-1044 日外宝第51巻第6号（昭和57年1月）Table 1. Summary of patients with dural AVl¥I in the anterior fosa. (# Incidental putaminal hemorrhage) S B I In tracranial I I Authors Year ! Age I ex ruit I hemorrhage I Treatm削 IResults 40～49 M 十＋｜？？40～49 M ー？Randa et al 1973 56 M + Removal Excellent Kosnik et al 1974 34 F + Waga et al 1977 46 M + Removal Excellent Takaku et al 1978 34 M Removal Excellent Bitoh et al 1981 61 M +# Removal Excellent ~~~~~：：t ~ta:!) : 1982 56 M + Removal Excellent ported that in dural AVl¥Is the draining cortical vein may be occasionally accompanied by a markedly dilated vascular sac, which may be embedded in the brain substance and associated with hemorrhage剖．Treatment of dural A VMs is often very di伍cult. Although some patients not treated or submitted only to obliteration of several feeding arteries may improve, occlusion of some of the afferent arteries either by operation or by means of endovascular procedures is usually insu伍cientto isolate these vascular anomalies from circulation. Direct surgical approach with removal of the malformation has been considered the best form of treatment. This is, however, impractical in dural AVMs involving the cavernous sinus, and technically often very dif五cult,if not impossible, in patients with lesions in the transverse-sigmoid sinus region. Fortunately，‘ a radical operative removal is usually possible in patients with dural A VMs located in the anterior cranial fossa. This was done in 6 out of 8 patients in the literature with uniformly excellent results (Table 1). In the remaining two patients, the detail of treatment is unknown. When the high incidence of complicating intracranial hemorrhage and the excellent operative results are taken into account, a radical operative procedure evidently is the treatment of choice in dural AVMs in this location. Oculomotor palsy seen in the present patient is not fully explained. A rupture of dural AV :¥1with formation of intracerebral hematoma and oculomotor palsy may have been coincidental. The patient was not diabetic or hypertensive, however, and other possible causes of oculomotor palsy such as an internal carotid aneurysm were not found. Contrast-filling of the S III segment of the superior ophthalmic vein and the cavernous sinus on the right side was poor in this patient. This fact may represent a high intravenous pressure secondary to a shunting of the arterial blood flowヲorit may be due to an occurrence of phle-bothrombosis in the cavernous sinus as often seen in the sigmoid sinus in patients with dural AVl¥Is in the posterior fossa. Abrupt occurrence of palpebral edema in the present case in the absence of local inflammatory signs is not incompatible with phlebothrombosis of, or an acute increase in pressure in, the cavernous sinus. If an outflow of the shunted blood into the cavernous sinus is acutely hindered by a process DURAL ARTERIOVE:¥'OじS:¥IALFOl<:¥IATIO:¥' 1045 of thrombosis within it. a diversion of flow may increase the pressure and自owwithin the alter native draining vein, causing its rupture. ＜‘onverseh・. an incidental rupture of a cortical draining vein with formation of hematoma around it may divert more blood into the cavernous sinus and cause a sharp rise of the pressure within the sinus. In such event＇、.the oculomotor palsy may be caused either by thrombosis or acute expansion of th巴cavernoussinus. Based on the presently available data, however, a definite conclusion cannot be drawn as to the pathogenesis of oculo-motor palsy in this particular patient. References 1) Aminoff ＼リ 1・ascularanomalies in the intracranial dura mater. Brain 96: 601-612, 1973. 2) Bitoh S, Nakagawa H, Arita N, Fujiwara M: Dural arteriovenous malformation in the anterior fossa. Case report. ：＼＇じurol¥led Chir (Tokyo) 21: 131-134, 1981. 3) Handa J, Shimizu Y: Dural arteriovenous anomaly supplied by anterior falcine artery. i¥ euroradiology 6: 212-214, 1973. 41 Houser OW. Baker HL, Jr., Rhoton AL, Jr., Oka四 l口H: Intracranial dural arteriovenous malformations. Radiology 105: 55 64, 1972. 5) Kosnik EJ, Hunt WE. ¥filer CA: Dural arteriovenous malformations. J Neurosurg 40: 322-329, 1974. 6) Newton TH, Hoyt ¥VF: Dural arteriovenous shunts in the region of the cavernous sinus. Neuroradiology 1: 71-81, 1970. 7) Nicola c;c Nizzoli V Dural arteriovenous malformations of the posterior fossa. J Neurol '.¥ •·uro、ur日Psychiatry 31 514-519, 1968. 8) Obrador日 Soto;¥'I, Silvela J: Clinical syndromes of arteriovenous malformations of the transverse sigmoid sinus. J ¥'eurol ¥'eurosur宮Psychiatry38: 436 451, 1975. 9) Takaku A, Sato T, Sakamoto T, Suzuki J: Dural arteriovenous malformation, with special consideration to its nature and treatment. Neural ¥led Chir rTokyol 18 (Part 1 67-74, 1978 10) Waga S, Fujimoto K, Morik川日A Morooka Y, Okada;¥! Dural arteriovenous malformation in the anterior fossa. Surg ¥'eurol 8:356-358, 1977. 1046 日外宝第51巻第6号（昭和57年11月）和文抄録前頭蓋喬の硬膜動静脈奇形滋賀医科大学脳神経外科木戸岡実，中洲 敏，中洲庸子，半田譲二56才男で，頭痛，意識障主，左眼険浮腫で発症し，眼険浮腫消組後右動眼神経麻療を呈した前頭蓋禽底面先端部の硬膜動静脈奇形（A＼・＼IIのl例を報告した．CTおよび血管撮影上 cristagalliの両側lζ存在したAV¥！／ま両側前飾骨動脈および右外頚動脈分岐より支配され， 導出静脈は軟膜静脈で海綿洞および上矢状洞lζ注さ．乙の静脈の一部lζ動脈癌様拡張が存在し，その周囲に脳内および硬膜下血腫をみとめた．前頭蓋寓 AVM は稀であるが，本f?IJを含め8例の報告例中7{91Jは男， 5例は頭蓋内血腫を併発し，記載の明らかな 5例中 4~Jで導出静脈に動脈癌様拡張をみとめた．頭蓋内出血の出血源は導出静脈側といわれる．との部の AVMは手術が比較的容易で好成績が得られる．頭蓋内出血の危険性を考慮して，根治手術を行なうべきである．

前頭蓋窩の硬膜動静脈奇形

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前頭蓋窩の硬膜動静脈奇形

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