Dural arteriovenous shunts in the region of the cavernous sinus
TL;DR: Dural arteriovenous shunts in the region of the cavernous sinus probably account for most so-called spontaneous carotid-cavernous Sinus cavernosus fistulae, and complete and selective cerebral angiography is essential for diagnosis.
Abstract: Dural arteriovenous shunts in the region of the cavernous sinus probably account for most so-called spontaneous carotid-cavernous sinus fistulae. Eleven patients with this type of dural shunt were found in a review of 30 carotid cavernous-sinus fistulae. These shunts usually appear in middle-aged women as a distinctive syndrome. The signs usually are mild and include dilated conjunctival veins, proptosis, and bruit. Transient sixth-nerve palsy and unilateral headache frequently antedate orbital signs by many months. Spontaneous resolution is common.—Complete and selective cerebral angiography is essential for diagnosis. The dural shunt is usually one of low flow and low pressure, allowing normal opacification of intracranial arteries during carotid arteriography. Arterial contributions to these fistulae arise from meningcal branches of the internal and external carotid arteries. Terminal meningeal branches of the internal maxillary artery are the most common source of blood from the external carotid artery that supply the fistula. The most frequent source from the internal carotid artery is the meningo-hypophyseal trunk. Contributions from the contralateral dural vessels were frequently observed. The fistula is usually situated posteriorly in the cavernous sinus and, in most instances, venous drainage extends anteriorly into the ophthalmic veins.
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TL;DR: A classification is proposed that unifies and organizes spinal and cranial dural arteriovenous fistulous malformations (AVFMs) into three types based upon their anatomical similarities.
Abstract: A classification is proposed that unifies and organizes spinal and cranial dural arteriovenous fistulous malformations (AVFMs) into three types based upon their anatomical similarities. Type I dural AVFMs drain directly into dural venous sinuses or meningeal veins. Type II malformations drain into dural sinuses or meningeal veins but also have retrograde drainage into subarachnoid veins. Type III malformations drain into subarachnoid veins and do not have dural sinus or meningeal venous drainage. The arterial supply in each of these three types is derived from meningeal arteries. The anatomical basis of the proposed classification is presented with several cases that illustrate the three types of dural AVFMs. A rationale for the treatment of spinal and cranial dural AVFMs according to their anatomical characteristics is discussed.
1,032 citations
TL;DR: The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.
Abstract: ✓ An anatomical-angiographic classification for carotid-cavernous sinus fistulas is introduced and a series of 14 patients with spontaneous carotid-cavernous sinus fistulas is reviewed to illustrate the usefulness of such a classification for patient evaluation and treatment. Fistulas are divided into four types: Type A are direct high-flow shunts between the internal carotid artery and the cavernous sinus; Type B are dural shunts between meningeal branches of the internal carotid artery and the cavernous sinus; Type C are dural shunts between meningeal branches of the external carotid artery and the cavernous sinus; and Type D are dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. The anatomy, clinical manifestations, angiographic evaluation, indications for therapy, and therapeutic options for spontaneous carotid-cavernous sinus fistulas are discussed.
1,028 citations
TL;DR: A comprehensive meta-analysis was performed on 360 additional dural AVM's reported in the literature with sufficiently detailed clinical and angiographic information and it was concluded that these features significantly increase the natural risk of duralAVM's, and warrant a more vigilant therapeutic strategy.
Abstract: The natural history of cranial dural arteriovenous malformations (AVM's) is highly variable. The authors present their clinical experience with 17 dural AVM's in adults, including 10 cases with an aggressive neurological course (strictly defined as hemorrhage or progressive focal neurological deficit other than ophthalmoplegia). Two of these 10 patients died prior to surgical intervention and a third was severely disabled by intracerebral hemorrhage. Six patients underwent surgical resection of their dural AVM, with preparatory embolization in two cases. One patient received embolization and radiation therapy without surgery. Six of the seven cases without an aggressive neurological course were treated conservatively, and the seventh patient underwent embolization of a cavernous sinus dural AVM because of worsening ophthalmoplegia. In order to clarify features associated with aggressive behavior, a comprehensive meta-analysis was performed on 360 additional dural AVM's reported in the literature with sufficiently detailed clinical and angiographic information. The location and angiographic features of 100 aggressive cases were compared to those of 277 benign cases. No location of dural AVM's was immune from aggressive neurological behavior; however, an aggressive neurological course was least often associated with cases involving the transverse-sigmoid sinuses and cavernous sinus and most often associated with cases at the tentorial incisura. Contralateral contribution to arterial supply and rate of shunting (high vs. low flow) did not correlate with aggressive neurological behavior as defined. Leptomeningeal venous drainage, variceal or aneurysmal venous dilations, and galenic drainage correlated significantly (p less than 0.05) with aggressive neurological presentation. The latter three angiographic features often coexisted in the same dural AVM. It is concluded that these features significantly increase the natural risk of dural AVM's, and warrant a more vigilant therapeutic strategy.
745 citations
TL;DR: The authors describe their experience with four cases of dural arteriovenous malformation (AVM) which led them to analyze the clinical aspects of these lesions in an attempt to understand their pathophysiology.
Abstract: The authors describe their experience with four cases of dural arteriovenous malformation (AVM) which led them to analyze the clinical aspects of these lesions in an attempt to understand their pathophysiology. An additional 191 previously reported cases of dural AVM's were reviewed with special attention to the mechanism of intradural, central, and peripheral nervous system manifestations. Apart from the peripheral cranial nerve symptoms, which are most likely due to arterial steal, the central nervous system (CNS) symptoms appear to be related to passive venous hypertension and/or congestion. Generalized CNS symptoms can be related to cerebrospinal fluid malabsorption due either to increased pressure in the superior sagittal sinus, to venous sinus thrombosis, or to meningeal reaction resulting from minimal subarachnoid hemorrhages. These phenomena are not related to the anatomical type of venous drainage. On the other hand, focal CNS symptoms are specifically indicative of cortical venous drainage. Seizures, transient ischemic attacks, motor weakness, and brain-stem and cerebellar symptoms can be encountered depending on the territory of the draining vein or veins. Therefore, the localizing value of focal CNS symptomatology relates to the venous territory and not to the nidus or to the arterial supply characteristics of dural AVM's. Furthermore, the venous patterns of various dural AVM's at the base of the skull are expressed by differences in their clinical presentation. Dural AVM's of the floor of the anterior cranial fossa and of the tentorium are almost always drained by the cortical veins and, therefore, have a high risk of intradural bleeding. The remarkable similarities in the manifestations of dural and brain AVM's and the differences in the manifestations of dural and spinal dural AMV's are pointed out. High-quality angiograms and a multidisciplinary approach to the study of dural AVM's will provide the best understanding of their symptoms and, therefore, the most appropriate treatment strategy.
597 citations
TL;DR: Patients with dural arteriovenous malformations, mostly located along the cranial base and in the occipitomastoid region, were studied angiographically and it was often possible to define a relationship between the clinical syndrome and the angiographic pattern of venous drainage.
Abstract: Twenty-eight patients with dural arteriovenous malformations, mostly located along the cranial base and in the occipitomastoid region, were studied angiographically. It was often possible to define a relationship between the clinical syndrome and the angiographic pattern of venous drainage. Intracranial hemorrhages occurred in those patients in whom the venous drainage of the arteriovenous malformation was limited to the pial veins, while the syndrome of a cavernous sinus fistula was present when retrograde venous drainage from the anomaly extended through the distensible ophthalmic veins. If the venous outflow was antegrade through the usual channels, the clinical syndrome reflected only the presence and volume of the arteriovenous shunt.
319 citations
References
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01 Jan 1965
218 citations
TL;DR: The clinical and angiographic features of 16 patients with dural arteriovenous malformations of the posterior fossa studied at the University of California Medical Center at San Francisco or Los Angeles or at the Karolinska Hospital in Stockholm, Sweden are presented.
Abstract: Arteriovenous malformations that involve the dura of the posterior fossa are rare, and they are therefore seldom considered in the differential diagnosis of posterior fossa lesions. Such malformations may involve the tentorium and the dura that covers the remainder of the posterior fossa. Their presence and extent can be evaluated accurately only by angiography. The purpose of this report is to present the clinical and angiographic features of 16 patients with dural arteriovenous malformations of the posterior fossa. These patients were studied either at the University of California Medical Center at San Francisco or Los Angeles or at the Karolinska Hospital in Stockholm, Sweden. Clinical Features The clinical features of the 9 males and 7 females are summarized in Table I. The ages ranged from one to sixty-eight years. In 11 patients a pulse-synchronous bruit was audible either at the vertex or over the mastoid region. Of these patients, 7 complained of hearing a pulsatile buzzing sound. Both the bruit a...
170 citations
"Dural arteriovenous shunts in the r..." refers background in this paper
...These dural shunts m a y involve the transverse sinus [13, 15, 24, 25], the sphenoparietal sinus [7, 16], the greater petrosal sinuses [1, 6, 10], the superior sagittal sinus [20], and the cavernous sinus [2, 4, 5, 8, 12, 14, 18, 21]....
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Journal Article•
164 citations
"Dural arteriovenous shunts in the r..." refers background in this paper
...A brief review based on the classic studies of Parkinson [17], therefore, is in order....
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...These twigs are derived from the artery to the inferior cavernous sinus and the dorsomeningeal branches of the meningo-hylJophyseal trunk [17]....
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134 citations
"Dural arteriovenous shunts in the r..." refers background in this paper
...The third intracavernous branch of the internal carotid artery, the capsular artery of McConnell [11], arises from the inferior medial wall of the internal carotid artery....
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TL;DR: The incidence of visual failure with carotid-cavernous fistula is high and it was impaired in 89% of the cases studied by de Schweinitz and Holloway and in 73% of those studied by Sattler.
Abstract: The incidence of visual failure with carotid-cavernous fistula is high. It was impaired in 89 per cent. of the cases studied by de Schweinitz and Holloway (I908) and in 73 per cent. of those studied by Sattler (I920). The latter recorded blindness or near blindness in almost half of his patients. Treatment has reflected a clinical preoccupation with elimination of the bruit and reduction of the proptosis, and modern methods have become increasingly proficient at obtaining this by more extensive surgery (Dandy, I935; Echols and Jackson, I959; Hamby, I966). However, in this condition, where the threat to life is small, preservation of vision becomes the major aim of therapy. Realisation of this goal has been lacking, though the ocular and cerebral hazards of surgery have recently been stressed by neurosurgeons (Walker and Allegre, I956; Stern, Brown, and Alksne, I967). Many articles and monographs have described the ocular complications of carotidcavernous fistula both before and after surgery, but the patho-physiology of these changes has never received the detailed and systematic attention it deserves. We have approached this problem by analysing critically the preoperative and postoperative causes of impaired vision in a series of 25 carotid-cavernous fistulae studied and treated at the University of California Medical Center during the past Io years. The changes that occurred in the eye, from the cornea to the optic nerve, were assessed in regard to: (i) Their effect on visual function. (2) Their appearance and resemblance to the hypoxic complications seen in other vascular diseases. (3) Their improvement or deterioration after neurosurgical procedures which alter the circulatory dynamics of the eye and orbit. Abnormalities in ocular perfusion, circulation time, and vascular permeability were recorded in selected cases by ophthalmodynamometry or fluorescein angiography.
132 citations
"Dural arteriovenous shunts in the r..." refers background in this paper
...These signs, in order of f requency were: proptosis (minimal in 8, moderate in 2) ; dilated conjunctival veins (minimal in 8, moderate in 1, and severe in 1) ; elevated intraocular pressure (mild in 7 and severe in 2); sixth-nerve palsy (partial in 4); objective bruit (loud in 3, high-pitched and focal in l, minimal in 2, bu t absent in 5); and major complications of ocular hypoxia, which led to monocular blindness, in 2 [22]....
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