くも膜下出血ならびに急性硬膜下血腫で発症した海綿静脈洞部硬膜動静脈短絡の1例

Cavernous Sinus Dural Arteriovenous Shunt Presenting with Subarachnoid Hemorrhage and Acute Subdural Hematoma : A Case Report

I．はじめに

　海綿静脈洞部硬膜動静脈短絡（cavernous sinusdural arteriovenous shunts，以下CdAVS）は一般に，眼球結膜の充血浮腫や眼球突出，雑音，眼球運動障害，頭痛，拍動性耳鳴で発症することが多く^5,8,11），頭蓋内出血を来すことはきわめて稀である^{3,6,8,10,13,14）}．今回われわれはくも膜下出血（subarachnoid hemorrhage，以下SAH）ならびに急性硬膜下血腫で発症し，結果的に救命し得なかったCdAVSの1例を経験したので報告する．

Cavernous sinus dural arteriovenous shunt (CdAVS) usually presents with exophthalmos, conjunctival chemosis, ophthalmoplegia, headache, bruit, or pulsatile tinnitus. Intracranial hemorrhage associated with CdAVS is rare. We describe a patient with CdAVS presenting with subarachnoid hemorrhage and acute subdural hematoma. A 65-year-old woman presented headache and temporary loss of consciousness and was transferred to our hospital. On admission, the patient was alert and complained of a left-sided tempor- al headache. There were no ocular symptoms. A CT scan revealed subarachnoid hemorrhage and left acute subdural hematoma. When we prepared for cerebralangiography, the patient presented loss ofconscious-ness following sudden onset of severe headache.Urgent angiography revealed left CdAVS, which wasfedby both the internal carotid artery and the externalcarotid artery and drained only into ipsilateral(left)vein of the sylvian fissure. Aneurysmal dilatationof the draining veins and leptomeningeal drainagewerepresent. No cerebral aneurysms were detected. Afterthe angiography, a CT scan showed enlarged subdu-ral hematoma, so left fronto-temporo-parietalcraniotomy was immediately performed. On opening theduramater, arterial bleeding from Sylvian fissureappeared and was uncontrollable. Unfortunately, thepatientdied 3 days after the operation. We concluded thatsubarachnoid hemorrhage and subdural hematoma weredue to the rupture of engorged cortical veins. Ourcase report suggests that CdAVS with angiographicfindings such as aneurysmal dilatation of thedraining veins and leptomeningeal drainage should betreatedurgently because of the high risk of thelife-threatening complications resulting from asurgically uncon-trollable hemorrhage.