|Year : 2021 | Volume
| Issue : 1 | Page : 46-48
A giant spontaneous dural arteriovenous fistula of the spheno-parietal sinus clinically masquerading as carotico-cavernous fistula: A case report
Dibya Jyoti Mahakul1, Rahul N Inganal2, Daljit Singh2
1 Department of Neurosurgery, Fortis Hospital, New Delhi, India
2 Department of Neurosurgery, GB Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
|Date of Submission||01-May-2021|
|Date of Decision||14-Jun-2021|
|Date of Acceptance||18-Jul-2021|
|Date of Web Publication||27-Aug-2021|
Dr. Dibya Jyoti Mahakul
Department of Neurosurgery, Fortis Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Dural arteriovenous fistulas (DAVF) are abnormal connections between the feeding arteries and veins within the dural leaflets and constitute 10%–15% of all intracranial arteriovenous malformations. DAVF draining into sphenoparietal sinus is a rare pathologic entity that is fed by the middle meningeal artery and is associated with a history of prior trauma. We report a unique case of DAVF of sphenoparietal sinus that had developed spontaneously. Being giant in morphology, it had eroded into the orbit and presented with proptosis, chemosis and restriction of eye movement. Although the clinical findings pointed towards caroticocavernous fistula, the real pathomorphology was unveiled by the six-vessel catheter angiography with selective catheterisation of smaller feeding vessels. All the feeding vessels were meticulously mapped out, and the fistulous connection was vividly identified and subsequently obliterated using detachable coils and n-butyl cyanoacrylate.
Keywords: Dural arteriovenous fistulas involving sphenoparietal sinus and orbit, giant dural arteriovenous fistulas of sphenoparietal sinus, spontaneous dural arteriovenous fistulas
|How to cite this article:|
Mahakul DJ, Inganal RN, Singh D. A giant spontaneous dural arteriovenous fistula of the spheno-parietal sinus clinically masquerading as carotico-cavernous fistula: A case report. J Cerebrovasc Sci 2021;9:46-8
|How to cite this URL:|
Mahakul DJ, Inganal RN, Singh D. A giant spontaneous dural arteriovenous fistula of the spheno-parietal sinus clinically masquerading as carotico-cavernous fistula: A case report. J Cerebrovasc Sci [serial online] 2021 [cited 2021 Dec 1];9:46-8. Available from: http://www.jcvs.com/text.asp?2021/9/1/46/324821
| Introduction|| |
Dural arteriovenous fistulas (DAVF) are a distinct pathologic entity that is characterised by abnormal connection between the feeding arteries and veins within the dural leaflets. These perilous lesions account for 10%–15% of all the intracranial arteriovenous malformations., Such vasculopathies are anatomically most prevalent at the junction of transverse and sigmoid sinus followed by the cavernous sinus. Accordingly, these present either with pulsatile tinnitus, headache or with ocular symptoms (such as chemosis, proptosis and vision loss). DAVF draining into the sphenoparietal sinus is a rare entity that involves middle meningeal artery (MMA) as feeding vessel and whose aetiology can mostly be traced back to a prior history of trauma., The primary curative strategy for such lesions is to meticulously identify the fistulous connections and occlude them through endovascular approach. We describe here a curious case of spontaneous giant DAVF involving the sphenoparietal sinus that had eroded its way into the orbit and presented with signs mimicking caroticocavernous fistula (CCF). However, six-vessel catheter angiography unraveled the exact angioarchitecture and aided in strategising the management plan.
| Case Report|| |
A 22-year-old male, without any known comorbidities or history of trauma, presented to our outpatient department with 18-month long history of gradually progressive proptosis, headache and pulse synchronous tinnitus in the left ear. Physical examination revealed bruit over the entire head but most significantly on the left temporal region, chemosis and restricted movements in the left eye. Although vision was normal in the right eye, he could not perceive light through his left eye. Contrast computed tomography imaging revealed a large intraconal, contrast-filled pouch that extends posteriorly into the intracranial compartment, causing pressure erosion and remodelling of lesser wing of sphenoid. The lesion caused marked orbital expansion and abaxial proptosis. T2 magnetic resonance imaging showed multiple flow voids in the left orbit, orbital apex and along the left anterior temporal and inferior frontal lobes [Figure 1]. Keeping vascular pathology as our first differential, we went ahead with a six-vessel cerebral digital subtraction angiography which showed a DAVF at the orbital apex, formed by an abnormal fistulous connection between the meningeal branches of left internal maxillary artery, MMA and left sphenoparietal sinus [Figure 2]. The dilated venous pouch at the sphenoid wing showed filling of dye from lateral to medial with subsequent filling of the orbital pouch through the inferior ophthalmic vein. Neither any feeder from left internal carotid artery was identified nor did it show any shunting into cortical vein. This angioarchitecture did fit into Cognard Type IIA DAVF. Endovascular treatment was offered to the patient. Selective catheterisation of MMA showed two abnormal connections, which were embolised using the transarterial route. First, we placed detachable coils in feeder vessel originating from the superficial temporal artery to slow down the flow and assist in subsequent embolisation using n-butyl-cyanoacrylate [Figure 3]. Post–procedure, there was a significant relief in proptosis, headache and tinnitus with angiographic obliteration of the fistulous connection.
|Figure 1: (a) Sagittal view of contrast computed tomography scan depicting a large intraconal contrast filled pouch that erodes the sphenoid wing and causes orbital expansion with displacement of globe anteriorly. (b) Contrast-enhanced magnetic resonance imaging depicting the flow void in the left orbit (intraconal) suggesting a high flow arteriovenous malformation|
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|Figure 2: (a) Anteroposterior view of digital subtraction angiography showing the dilated venous pouch at the sphenoid wing and filling of dye from lateral to medial with subsequent filling of the orbital pouch. (b) Digital subtraction angiography showing a dural arteriovenous fistulas at the orbital apex, formed by an abnormal fistulous connection between the meningeal branches of left internal maxillary artery, middle meningeal artery and left sphenoparietal sinus. (c) Lateral view of digital subtraction angiography of left internal carotid artery showed neither any feeder from left internal carotid artery nor did it|
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|Figure 3: Lateral view of digital subtraction angiography through external carotid artery shows the initial placement of detachable coils in feeder vessel originating from the superficial temporal artery, (a) which slowed down the flow and assist in subsequent embolisation (b) using n-butyl cyanoacrylate. (c) Post-procedure common carotid artery run showing angiographic obliteration of the fistulous connection|
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| Discussion|| |
Although DAVF is considered as an acquired pathology that presents with antecedent events such as trauma, surgery or venous sinus thrombosis, many a times we encounter cases that are without such prior history. DAVF of sphenoparietal sinus, being even rarer, shadows our understanding of the aetiopathogenesis., What accounts for the curiosity in this case is the lack of prior history of trauma, the bony erosion associated, suggesting chronicity and the large size of the venous pouch which extended from the anterotemporal region into the orbit. Although clinical mimicry allured us initially towards a more common pathology, CCF, a six-vessel angiography helped us in zeroing on the exact angioarchitecture and correct diagnosis. The presence of ocular symptoms and tinnitus usually point towards the involvement of cavernous sinus and transverse sinus, respectively. However, in our case, blood through the fistulous tract initially drained into the sphenoparietal sinus and then flowed retrogradely into the orbit through the inferior ophthalmic vein. This accounted for the proptosis and restriction of eyeball movement. Moreover, the vision deterioration was due to the overgrowth of granulation tissue as a response to exposure keratitis, rather than due to the increased venous pressure as in a true CCF. Such a quirky clinical presentation may misguide us while framing a proper plan of intervention.
| Conclusion|| |
We have described an unusual case of a large spontaneous DAVF involving the sphenoparietal sinus. Clinical presentation of DAVF can vary and may even mimic a CCF. One needs to be vigilant enough to correctly diagnose this pathology and chalk out a good treatment strategy. A six-vessel angiography and selective catheterisation of the smaller vessels enables us to map out the feeder arteries and identify the fistulous connections.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]