경도인지장애로 나타난 광범위한 정맥 울혈을 동반한 경막동정맥샛길

Dural Arteriovenous Fistula with Extensive Engorged Vein Manifested as Mild Cognitive Impairment

Article information

J Korean Neurol Assoc. 2023;41(4):344-345
Publication date (electronic) : November 1, 2023
doi : http://dx.doi.org/10.17340/jkna.2023.0027
Department of Neurology, Veterans Health Service Medical Center, Seoul, Korea
김정섭, 배희원
보훈공단 중앙보훈병원 신경과
Address for correspondence Heewon Bae, MD Department of Neurology, Veterans Health Service Medical Center, 53 Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul 05368, Korea Tel: +82-2-2225-1324 Fax: +82-2-2225-1327 E-mail: communis@nate.com
received : April 6, 2023 , rev-recd : June 29, 2023 , accepted : June 29, 2023 .

78세 여자 환자가 한달 전부터 발생한 기억력 저하로 내원하였다. 신경계진찰은 정상이었고, 도구 일상활동은 단기 기억에서 1점으로 0.09에 해당하며, 간이 정신 상태 검사는 23점으로 교육연수 12년 고려 시 경도인지장애에 해당하였다. 뇌 자기공명영상 결과 T2 강조영상에서 뇌 전반의 피질 및 숨뇌정맥 울혈이 있었고, 자화율 강조영상(susceptibility-weighted imaging)에서 전두측두엽 부위의 미세출혈이 확인되었다(Fig. A-D). 대퇴동맥경유뇌혈관조영(transfemoral cerebral angiography)에서는 왼쪽 횡정맥동(transverse sinus)과 구불정맥동(sigmoid sinus)에 누공이 보여 왼쪽 횡정맥동의 색전술을 시행하여 동정맥루를 완전 폐색했다(Fig. E-H). 시술 2달 후 시행한 간이 정신상태 검사는 26점으로 상승하였고, 호소하던 기억 저하도 호전되었다. 박동성 이명이 경막동정맥샛길의 흔한 증상이나, 급격한 치매로 발현되는 증례가 여럿 보고된 바 있다. 하지만 본 증례처럼 광범위피질 및 숨뇌 정맥 울혈이 있을 때 경련 혹은 소뇌 증상 등의 신경계 증상 없이 경미한 기억 저하를 보이는 경우는 드물다[1,2]. 경막동정맥샛길에 의한 인지기능 저하는 혈관 내 색전술을 통해 회복 가능하므로 조기 진단이 중요하다.

Figure.

(A, B) T2-weighted images showed engorged cortical (red arrows) and medullary veins (red arrowheads) in the supra and infratentorial regions. (C, D) SWI reveals venous engorgement in the cortical and medullary veins (white arrows) and microhemorrhages in the frontotemporal regions (yellow arrows). (E) Angiography from left internal carotid artery reveals venous congestion and drainage through right transverse-sigmoid-jugular pathway (yellow arrowheads). (F) Angiography approach through the left external carotid artery indicates that the fistula (white arrowhead) is being filling through the left occipital, posterior auricular, superficial temporal, and middle meningeal arteries. (G) The bulbous section of the left transverse sinus (white arrow) is the target for coil insertion to achieve venous occlusion during embolization. (H) Post-embolization angiography revealed that the arteriovenous fistula was closed (black arrowhead) and displayed regular flow direction of drainage. SWI; susceptibility-weighted image.

References

1. Henderson JB, Zarghouni M, Hise JH, Opatowsky MJ, Layton KF. Dementia caused by dural arteriovenous fistulas reversed following endovascular therapy. Proc (Bayl Univ Med Cent) 2012;25:338–340.
2. van Rooij WJ, Sluzewski M, Beute GN. Dural arteriovenous fistulas with cortical venous drainage: incidence, clinical presentation, and treatment. AJNR Am J Neuroradiol 2007;28:651–655.

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Figure.

(A, B) T2-weighted images showed engorged cortical (red arrows) and medullary veins (red arrowheads) in the supra and infratentorial regions. (C, D) SWI reveals venous engorgement in the cortical and medullary veins (white arrows) and microhemorrhages in the frontotemporal regions (yellow arrows). (E) Angiography from left internal carotid artery reveals venous congestion and drainage through right transverse-sigmoid-jugular pathway (yellow arrowheads). (F) Angiography approach through the left external carotid artery indicates that the fistula (white arrowhead) is being filling through the left occipital, posterior auricular, superficial temporal, and middle meningeal arteries. (G) The bulbous section of the left transverse sinus (white arrow) is the target for coil insertion to achieve venous occlusion during embolization. (H) Post-embolization angiography revealed that the arteriovenous fistula was closed (black arrowhead) and displayed regular flow direction of drainage. SWI; susceptibility-weighted image.