特異な血行動態を呈したHigh-flow外傷性後頭蓋窩硬膜動静脈瘻の全摘出例

A Case of Successfully Removed Posttraumatic High Flow Dural Arteriovenous Fistula in the Posterior Fossa

I．はじめに

　横静脈洞部やS状静脈洞部に発生する後頭蓋窩硬膜動静脈瘻は，血管撮影法の進歩とともにけっして稀な疾患でないことが明らかとなり，外科的治療報告も多い．しかし，一般的に根治は困難で再発例もしばしばみられる．われわれは，49歳男性，頭部外傷の3年後にけいれん発作で発症し，数度の流人動脈遮断術にもかかわらず，17年間に著明な側副血行を形成した後頭蓋窩硬膜動静脈瘻に対して手術を行い，閉塞した横静脈洞を含めて全摘に成功したので報告する．

Abstract

A 49-year-old male patient was admitted to Ryukyu University Hospital complaining chiefly of progressive loss of mental activity for one year. He had a history of head trauma at the right retromastoid region when he was 24. Generalized convulsions developed three years later, and left exophthalmos, facial varix and impair-ment of visual acuity developed seven years later. Du-ral arteriovenous fistula of the posterior fossa was dia-gnosed at the age of 32, and feeding EC and tentorial arteries were successively ligated on the right several times without any effect.

Angiography during this admission revealed tremen-dous collateral flows ; a marked dilated tortuous occi-pital artery fed from the right vertebral artery, mening-eal branches of VA and PICA, the marginal tentorial artery, and the posterior temporal artery from MCA, PCA were drained into the right transverse sinus. But transverse sinuses were occluded bilaterally, and venous outflows were directed to the superior sagittal sinus retrograde via the ascending cortical vein, Trolard veins, and sphenoparietal and cavernous sinuses. The final drainer was the superior ophthalmic vein on the left. Normal deep veins were not visible. In park bench position, the nidus was totally resected with a part of the transverse and thrombosed sigmoicl sinus. Postop-erative course was uneventful, and an angiogram showed complete disappearance of the AVF.

Dural AVF in the posterior fossa with characteristics such as high flow, and which is rich in collaterals fol-lowing palliative treatment indicates that total surgical resection should be undertaken.