Dural Arteriovenous Malformation Involving the Inferior Petrosal Sinus

— Case Report—

Masaru YAMADA, Yoshio MIYASAKA, Yukio KITAHARA, Kenzo YADA, and Shinichi KAN*

Departments of Neurosurgery and *Radiology, Kitasato University School of Medicine, Sagamihara, Kanagawa

Abstract

A 59-year-old male presented with a dural arteriovenous malformation involving the inferior petrosal sinus manifesting as false-localizing ocular symptoms. Occlusion between the right inferior petrosal sinus and the right jugular bulb caused an unusual retrograde venous outflow from the inferior petrosal sinus to the cavernous sinus, thought to have been responsible for the chemosis, abducens nerve paresis, and orbital bruit. He was treated successfully with transarterial embolization and radiotherapy.

Key words: dural arteriovenous malformation, inferior petrosal sinus, ocular symptoms , draining vein

Introduction right mastoid region. Neurological examination revealed only slightly limited sursumversion and dex Dural arteriovenous malformations (AVMs) involv troversion. Fundoscopic examination found no ing the inferior petrosal sinus (IPS) are very rare," papilledema. Laboratory tests showed the presence with only six previously reported cases.2) We describe of diabetes mellitus, but no other abnormalities. We a patient with a dural AVM at the IPS with a very suspected a spontaneous carotid-cavernous fistula on unusual occlusion between the right IPS and the the right. right jugular bulb, manifesting as false-localizing Right common carotid angiography showed ocular symptoms. opacification of the right IPS in the early arterial phase, and drainage of the right IPS anteriorly into Case Report the right cavernous sinus and the dilated right superior ophthalmic vein (SOV), and posteriorly into In August, 1987, a 59-year-old male noticed that his the deep cervical vein via the condylar emissary vein right eye was blood-shot. He was referred to our (Fig. 1). The right transverse sinus, the right sigmoid department by a local ophthalmologist in sinus, and the right internal jugular vein were not September, 1987, after complaining of double vision opacified in the venous phase. Right external carotid during dextroversion. He had also noticed a con angiography disclosed an enlarged occipital artery, tinuous murmur in the right occipital region per an enlarged ascending pharyngeal artery, the nidus sisting for 10 months. of the AVM, and the same pattern of venous Examination on admission found conjunctival drainage seen in the right common carotid chemosis of the right eye with swelling of the right up angiogram. The right internal carotid angiogram was per eyelid, but no exophthalmos or ocular pulsation. normal. No connection was discovered between the Auscultation detected bruit in the right orbit and right and left cavernous sinuses. Selective angiography of the right occipital artery clearly show Received May 14, 1993; Accepted November 2, ed the nidus of the AVM draining into the IPS (Fig. 1993 2). Left common carotid and left vertebral angiograms showed the left ascending pharyngeal artery and the dural branches of the right vertebral artery were feeding arteries. The transverse sinus, the sigmoid sinus, and the internal jugular vein on the right were clearly opacified in the venous phase of left common carotid angiography, indicating that the connection between the right IPS and the right jugular bulb was occluded. The diagnosis was a dural AVM involving the right IPS, fed by the right occipital artery, the bilateral ascending pharyngeal arteries, and dural branches of the right vertebral artery, and drained by the right IPS, the right caver nous sinus, and the right SOV anteriorly, and the right condylar emissary vein and the right deep cer Fig. 1 Right common carotid angiograms, antero vical vein posteriorly. Figure 3 shows a schematic posterior (left) and lateral views (right), show presentation of the angiographic findings. ing early opacification of the IPS (arrow), the We performed transarterial embolization with cavernous sinus, the SOV (arrowhead), and Ivalon through all feeding arteries except the the deep cervical vein. vertebral artery. The conjunctival chemosis and swelling of the right eye had declined, and the diplopia had disappeared when he was discharged after 4 hospital months. Right abducens nerve paresis developed again in May, 1988, with the same angiographic findings as before. Conventional radiotherapy (local, 50 Gy) was used as an adjunctive therapy. In December, 1992, the paresis still persisted, but angiography showed complete disappearance of the dural AVM and no opacification of the right IPS, while the right internal jugular vein was opacified normally (data not shown).

Discussion Fig. 2 Lateral view of the selective angiogram of the right occipital artery, demonstrating the nidus Only six dural AVMs of the IPS have previously (arrowhead) draining into the IPS (arrow). been reported with angiographic features (Table 1).2)

Fig. 3 Schematic drawings, axial (left) and lateral views (right), showing the relationship of the nidus to the venous sinuses and direction of the shunt flow (arrows). The sinus occlusion (asterisk) was located between the IPS and the jugular bulb. Table 1 Dural AVMs of the IPS

The arterial supply in all patients was from branches cavernous sinus-SOV). Normally, venous flow from of the external carotid artery, and in three also in the IPS empties orthograde into the jugular bulb and volved the meningohypophyseal trunk of the internal the internal jugular vein. In our patient, normal carotid artery. Venous drainage was via the jugular venous outflow was disrupted by the occlusion be bulb in five patients and the cavernous sinus and tween the right IPS and the right jugular bulb, so SOV in four. The pattern of arterial supply and the that the venous flow was mainly retrograde into the location of the nidus in our case were very similar to cavernous sinus and the orbit. Lasjaunias et al.') con these previous cases. However, in our patient, the sidered that this type of manifestation is a "venous connection between the right IPS and the right mass effect," which often occurs with cranial jugular bulb was occluded, despite the patency of the neuropathy in cavernous sinus dural AVMs. internal jugular vein. Only Barnwell's case 4 had the The series of Barnwell et al.') included four pa same peculiar sinus occlusion, while Takekawa and tients with retrograde venous drainage into the caver Holman5) and Takahashi et al.4) reported similar nous sinus, and three of whom also had orthograde dural AVMs, but did not describe this particular drainage into the jugular bulb. The ocular symptoms sinus occlusion. The angiographic characteristics are in our patient probably resulted from the disturbed also very unusual, due to the location of the dural venous flow through the right internal jugular vein. AVM and the peculiar venous drainage pattern due to the unusual sinus occlusion. References Barnwell et al.') pointed out that the signs and symptoms of a dural arteriovenous fistula (AVF) in 1) Awad IA, Little JR, Akrawi WP, Ahl J: Intracranial volving the IPS are similar to those of dural AVF in dural arteriovenous malformations: Factors predispos volving the cavernous sinus, including bruit, prop ing to an aggressive neurological course. J Neurosurg tosis, decreasing vision, and abducens nerve paresis. 72: 839-850, 1990 They stressed the relationship between such symp 2) Barnwell SL, Halbach VV, Dowd CF, Higashida RT, toms and the pattern of venous drainage (IPS Hieshima GB: Dural arteriovenous fistulas involving the inferior petrosal sinus: Angiographic findings in of anomalous communications between the external six patients. AJNR 11: 511-516, 1990 carotid artery and intracranial veins. Amer JRoentgen 3) Lasjaunias P, Chiu M, Ter Brugge K, Tolia A, Hurth 95: 822-825, 1965 M, Bernstein M: Neurological manifestations of in tracranial dural arteriovenous malformations. J Neurosurg 64: 724-730, 1986 4) Takahashi A, Mizoi K, Yoshimoto T: Marginal sinus Address reprint requests to: M. Yamada, M.D., Depart dural arteriovenous shunts: Clinical, angiographical ment of Neurosurgery, Kitasato University School of and therapeutic considerations. Nosocchu No Geka Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 20: 384-390, 1992 (in Japanese) 228, Japan. 5) Takekawa SD, Holman CB: Roentgenologic diagnosis