Sinus excisionとdirect sinus packingの併用により根治した横-S状静脈洞・硬膜動静脈瘻の1例

Joint Therapy of a Dural Arteriovenous Fistula in the Transverse-Sigmoid Sinus Using Surgical Excision and Direct Sinus Packing : A Case Report

　Ⅰ．はじめに

　頭蓋内硬膜動静脈瘻（dural arteriovenous fistula : dAVF）は，特に脳静脈への逆流を伴う場合，頭蓋内出血や白質障害により予後が不良となりやすい^1,4,12)．治療法として，経静脈的あるいは経動脈的塞栓術，小開頭によるdirect sinus packingあるいは外科的摘出などが報告されている．現在，病変静脈洞の開存の有無などにより，治療法が選択されている^5,11)．

　今回，われわれは，病変が頸静脈孔まで及んでいる横-S状静脈洞dAVFに対して，S状静脈洞下部の病変にはdirect packingを，横静脈洞，上部S状静脈洞の病変には摘出術を行うことで，安全に完治し得た症例を経験したので報告する．

　Combined therapy of direct sinus packing and surgical excision for intracranial dural arteriovenous fistula (dAVF) has not been reported in the literature. A 53-year-old male was admitted to our hospital due to sudden onset of seizure and consciousness disturbance. Plain CT scan showed subcortical hematoma in the right temporal lobe. Cerebral angiography revealed dAVF involved in the right transverse and sigmoid sinuses. The lesion was associated with retrograde venous drainage into the right cerebellum,temporal,and occipital lobes. Positron emission tomography (PET) showed typical findings of venous hypertension in the involved areas. MRI also demonstrated a high intensity lesion in the medulla oblongata,suggesting critical venous congestion. First,we aimed to pack the involved sinus through a minor craniotomy,but cannulation into the sinus was impossible probably because of a marked fibrosis in the involved sinus. Then,we completely exposed the involved sinus through craniotomy. Through a microcatheter inserted into the sinus,the lower part of the sigmoid sinus was directly packed,and the remaining lesion was excised. Postoperative course was uneventful. Disappearance of dAVF resolved the findings on PET and MRI. Combined therapy would be a safe,non-invasive,and useful option for patients with a complex intracranial dAVF.