下錐体静脈洞経由塞栓術のみでは治癒しえなかった海綿静脈洞部硬膜動静脈瘻症例の検討  [in Japanese] Cavernous Sinus Dural Arteriovenous Fistula Unresponsive to Transvenous Embolization Via the Inferior Petrosal Sinus  [in Japanese]

従来, 海綿静脈洞部硬膜動静脈瘻(cavernous sinus dural arteriovenous fistula:CdAVF)の治療法として徒手的頸動脈圧迫法, 経動脈的塞栓術(transarterial embolization:TAE)などが施行されてきたが, 近年の脳血管内治療の進歩に伴い経静脈的塞栓術(transvenous embolization:TVE)が治療の主流となった. TVEに際し海綿静脈洞(cavernous sinus:CS)への到達法として最も一般的に選択される経路は下錐体静脈洞(inferior petrosal sinus:IPS)であり, 実際IPS経由でのTVEのみで根治を得ることが可能なCdAVF症例は多い. しかし, IPS経由のみでは治療が困難な症例も時に経験され, このような場合, 別の到達経路や異なった治療方法の検討, 選択が必要となる. 今回IPS経由でのTVEのみでは根治しえず, 別経路からの追加塞栓術を必要としたCdAVF症例につき検討を行った. 対象 過去6年間にTVEを施行したCdAVF16例を対象とした. この対象例中, IPS経由でのTVEのみではCdAVFを根治しえず, 追加治療を必要とした症例は3例(18.8%)であった.

Recent advances in intravascular surgical technique have made it possible to choose transvenous embolization (TVE) as the first therapeutic procedure of cavernous sinus dural arteriovenous fistula (CdAVF). While the inferior petrosal sinus (IPS) is the most common approach route to the cavernous sinus (CS), embolization through the IPS is difficult in some patients. We report 3 cases who underwent TVE via IPS and latter required additional TVE via another approach. Subjects were 3 of 16 patients with CdAVF who underwent TVE at our institution in the past 6 years. Case 1 had bilateral CdAVF (the right side was more severe). Initially, TVE was performed through the left CS via the intercavernous sinus (intCS) from the right IPS, and the posterior component of the right CS was occluded at the end. This partial embolization of the right CS induced increase of reflux to the right superior ophthalmic vein (SOV) causing exacerbation of proptosis on the right side. Transarterial embolization via the ascending pharyngeal artery decreased reflux to the right, SOV immediately. TVE through the SOV was undertaken 1 week later and the fistula was completely occluded. In Case 2, embolization was performed through the patent IPS. During TVE, the coil accidentally became detached, and another coil was placed from the contralateral CS via the int,CS. Reflux to the SOV diminished transiently, but recurred because the IPS, one of the outflow paths, became occluded. Hence additional TVE via the SOV was required to completely occlude the fistula. In Case 3, although the CS could be reached from the IPS, the venous pouch in which the fistula had occurred could not be reached due to trabeculae within the CS. TVE by the direct puncture of SOV successfully occluded the fistula. When treating CdAVF by TVE, it is necessary to not only carefully ascertain the location of the fistula and ensure thorough packing but also to utilize multiple approaches and combine TAE as necessary.