脳 A Judgment and Action for Dural Arteriovenous Fistula Junichiro Satomi, M.D., and Shinji Nagahiro, M.D. Key words Jpn J Neurosurg Tokyo , 20

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1 脳 A Judgment and Action for Dural Arteriovenous Fistula Junichiro Satomi, M.D., and Shinji Nagahiro, M.D. Key words Jpn J Neurosurg Tokyo , 2016 緒言 dural arteriovenous fistula DAVF dural arteriovenous malformation dural arteriovenous shunt dural arteriovenous fistulous shunt terminology malformation DAVF S

2 Table 1 Classification of DAVF Classification based on venous drainage pattern Borden 4, Cognard 7. Borden type Cognard type Site of venous drainage Flow characteristics CVD absent Dural sinus Antegrade sinus flow a Dural sinus Retrograde sinus flow CVD present b Dural sinus Antegrade sinus flow, CVD a b Dural sinus Retrograde sinus flow, CVD CVD Nonectatic cortical vein CVD Ectatic cortical vein CVD Spinal perimedullary vein CVD cortical venous drainage Classification from biological and or developmental difference Geibprasert 11 1 Ventral epidural shunts osteo cartilaginous epidural Vertebral body, basioccipital, sigmoid sinus, petrous pyramid, basisphenoid and adjacent sphenoid wings, and related dural structures. 2 Dorsal epidural type osteo membranous epidural Dorsal spinal epidural DAVS, marginal sinus dorsal portion, medial occipital sinus, torcular, transverse and accessory epidural sinuses, and superior sagittal sinus. 3 Lateral epidural type Spinal DAVS, marginal sinus lateral portion foramen magnum with the emissary bridging vein to the condyloid vein, falcotentorial vein of Galen, petrosal and basitentorial, Breschet sinus, paracavernous sinus region embryonic tentorial sinus remnants, intraorbital shunts, and lamina cribriformis. DAVS dural arteriovenous shunt 成因, 病理 Sarma m 18 VEGF bfgf 分類 Table 1 Borden 4 Cognard 7 Jpn J Neurosurg VOL. 25 NO

3 a b a b Geibprasert 11 ventral epidural VE lateral epidural LE dorsal epidural DE VE DE LE 重症度との関連 S Willinsky 40 pseudophrebitic pattern 疫学 Newton Mayo Clinic 本邦での悉皆調査 , , ,490 1, S condylar vein

4 自然歴 Piton 24 Cognard benign type aggressive type 27 Shah 32 benign type aggressive type 1 0 aggressive type van Dijk Duffau dynamic aggressive nature DAVF venous ectasia Gross 13 Borden type Borden type Zipfel 42 benign symptoms v.s stage palliative embolization 決定木解析を用いた硬膜動静脈瘻の 29 重症化予測 1 Jpn J Neurosurg VOL. 25 NO

5 n: 89 HI: 51 NHI: 38 Incidental No n: 73 HI: 50 NHI: 23 Cortical venous drainage No n: 40 HI: 17 NHI: 23 Location Yes Yes Tentorium n: 16 HI: 1 NHI: 15 NHI n: 33 HI: 32 NHI: 1 HI n: 3 HI: 3 NHI: 0 HI n: 19 HI: 7 NHI: 12 Chemosis Cavernous sinus Hypoglossal canal n: 3 HI: 0 NHI: 3 NHI Transverse / sigmoid sinus n: 15 HI: 8 NHI: 7 Tinnitus Yes No No Yes n: 15 HI: 7 NHI: 8 Tinnitus n: 4 HI: 0 NHI: 4 NHI n: 9 HI: 7 NHI: 2 HI n: 6 HI: 1 NHI: 5 NHI No n: 13 HI: 5 NHI: 8 NHI Yes n: 2 HI: 2 NHI: 0 HI HI: Hemorrhage/Infarction NHI: No Hemorrhage/Infarction Fig. 1 The decision tree generated for predicting the risk for hemorrhage infarction in DAVF patients 29 Fig S S 硬膜動静脈瘻の診断, 治療 Willems 39 4 D CTA small slow

flow DAVF の検出には不十分であるが診断フォロートの手前での流入動脈の塞栓は根治性に乏しい pallia- アップのツールとして期待されるとしているまた

迷入は起こしにくい皮質静脈逆流を有さない硬膜動静と 93 の正診率であり静脈還流形態による病型分類脈瘻に対する部分塞栓術は無治療のものと比べ耳鳴

transosseous DAVF41 Fig. 2 や硬膜外に短絡部位が存在し硬膜外静脈叢に流出する extradural AVF Fig.

シャントの不完全閉塞は先に述べたような症状悪化につながることもあり合併症に注意しつつ可能なかぎりシャント閉塞に努めることが望ましい治療法として血管内治療

showed that the DAVF was fed mainly by the right middle meningeal artery with drainage

3 Extradural AVF demonstrated a shunt between the arteries and extradural venous

6 flow DAVF の検出には不十分であるが診断フォロートの手前での流入動脈の塞栓は根治性に乏しい pallia- アップのツールとして期待されるとしているまた tive embolization ものの脳神経麻痺や頭蓋内動脈への Farb ら10 は time resolved 3T MR angiography を用いる迷入は起こしにくい皮質静脈逆流を有さない硬膜動静と 93 の正診率であり静脈還流形態による病型分類脈瘻に対する部分塞栓術は無治療のものと比べ耳鳴も可能であったと報告している古典的な DAVF に似た病態として狭義の DAVF の範疇からは外れるが骨内の導出静脈に短絡部位が存在し板間静脈に流出する transosseous DAVF41 Fig. 2 や硬膜外に短絡部位が存在し硬膜外静脈叢に流出する extradural AVF Fig も存在する硬膜動静脈瘻の治療はシャントの消失を目的とするのではなく症状の改善と重篤な発症を未然に防ぐことを第一義に考えねばならないしかしながらシャントの不完全閉塞は先に述べたような症状悪化につながることもあり合併症に注意しつつ可能なかぎりシャント閉塞に努めることが望ましい治療法として血管内治療外科的治療放射線治療およびそれらの組み合わせがある血管内治療の方法として経動脈的塞栓経静脈的塞栓が挙げられる経動脈的塞栓は塞栓物質により効果の違いがあるコイルや粒子によるシャン A B D E Fig. 2 DAVF in the region of the frontal bone Right external carotid artery angiography showed that the DAVF was fed mainly by the right middle meningeal artery with drainage into the diploic veins41. C Fig. 3 Extradural AVF demonstrated a shunt between the arteries and extradural venous plexus A early arterial phase, B late arterial phase, C scheme. Whole packing of extradural venous plexus is mandatory D angio30. gram after embolization of the epidural venous plexus, E scheme Jpn J Neurosurg VOL. 25 NO

A and the sylvian vein drained into the cavernous sinus in the normal venous phase B, C.

cerebellar veins through the petrosal vein D. Transvenous embolization of the petrosal vein and cavernous sinus led to complete shunt occlusion E.

療にならないよう留意しなければならない 3 静脈瘻において有効なことが多く根治性が高い curative embolization しかしながら脳神経栄養血管頭蓋内動脈への迷入静脈側への流出などのトラブルを起海綿静脈洞部硬膜動静脈瘻の治療法こすリスクを有する諸外国においては

は今なお有用であり Onyx の功罪についてはいまだ不が挙げられる海綿静脈洞へのシャントそのものによる明な点が多いとする high volume institute からの報外眼筋麻痺三叉神経症状海綿静脈洞症候群下錐体 14 19 告

7 A B C E D Fig. 4 Cavernous sinus DAVF presenting with tinnitus Angiogram of the initial assessment demonstrated the inferior petrosal sinus as a venous drainage A and the sylvian vein drained into the cavernous sinus in the normal venous phase B, C. Angiogram performed five months after partial embolization of the cavernous sinus demonstrated retrograde leptomeningeal venous drainage into the cerebellar veins through the petrosal vein D. Transvenous embolization of the petrosal vein and cavernous sinus led to complete shunt occlusion E. の減少につながるものの神経症状の改善はみられないとがあるまた皮質静脈逆流を助長することもありとした報告もある一方シャント閉塞を目的とした先に記した硬膜動静脈瘻のグレードを高める方向への治液体塞栓物質による塞栓は特にグレードの高い硬膜動療にならないよう留意しなければならない 3 静脈瘻において有効なことが多く根治性が高い curative embolization しかしながら脳神経栄養血管頭蓋内動脈への迷入静脈側への流出などのトラブルを起海綿静脈洞部硬膜動静脈瘻の治療法こすリスクを有する諸外国においては Onyx を用いた海綿静脈洞は硬膜動静脈瘻の好発部位であるが他の塞栓術の報告が多くみられるようになってきたが従来部位とは異なるいくつかの特徴を有するまず流出静の acrylic glue による経動脈的シャントポイント塞栓術脈路が多方向に存在するため多彩な症状を呈することは今なお有用であり Onyx の功罪についてはいまだ不が挙げられる海綿静脈洞へのシャントそのものによる明な点が多いとする high volume institute からの報外眼筋麻痺三叉神経症状海綿静脈洞症候群下錐体告静脈洞を主とした後方への流出による耳鳴前方の上経静脈的塞栓は主に硬膜静脈洞にシャントが存在す眼下眼静脈への流出による眼瞼浮腫眼球突出結膜る場合に適用されるがシャントの本態は硬膜静脈洞充血といった前眼部症状が挙げられるこれらはシャ壁内にあるためできるかぎりシャント近傍のコンポーント消失に伴い症状が軽快することが多い一方網膜ネントをコイルにて塞栓することがポイントである不中心静脈への逆流は不可逆性の視力低下をきたすことが用意に静脈洞内の大きなコンポーネントを閉塞するとあり皮質静脈逆流と同様に重症として捉える必要があ残存したシャントに再び接近することができなくなるこる皮質静脈への逆流経路としてシルヴィウス静脈大 48 も散見される脳外誌 25 巻 1 号 2016 年 1 月

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10 要旨 DAVF DAVF DAVF DAVF NBCA Onyx 脳外誌 25:42 51,2016 Jpn J Neurosurg VOL. 25 NO

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A indd 184 Dementia Japan 24 : 184-190, 2010 原著要旨 davf davf 128 6 MRI SPECT 12% S 25% Characteristic of a dural arteriovenous fistulae (davf)producing symptoms of dementia Sachio Suzuki 1, Akira Kurata 1, Satoshi