Durafisteln mit intrakranieller Blutung: Diagnostische und therapeutische Aspekte

Zusammenfassung

Sieben Patienten wiesen eine intrakranielle Blutung infolge arteriovenöser duraler Fisteln auf. In sechs Fällen lagen intrazerebrale Hämatome vor, jeweils einmal kombiniert mit einem Subduralhämatom und einer intraventrikulärer Blutung, in einem Fall bestand eine infratentorielle Subarachnoidalblutung. Die Lage der Fisteln war frontobasal (n=2), Tentorium (n=2), Sinus transversus (n=2) und Sinus sagittalis superior (n=1). In allen Fällen bestand angiographisch ein Reflux in kortikale Hirnvenen. Die Therapie war chirurgisch bei den frontobasalen Fisteln mit jeweils gutem Ergebnis. Eine alleinige endovaskuläre, intraarterielle Therapie empfahl sich bei einer umschriebenen Fistel zum Sinus sagittalis superior, dieser Patient entwickelte später eine weitere durale Fistel. Zwei Patienten mit Fistel des Tentoriums wurden initial endovaskulär behandelt, wobei einmal Infarzierungen des Thalamus beidseits auftraten, im anderen Falle kam es zu einem Fistelrezidiv. Die Fistel im letzteren Fall wurde sekundär chirurgisch verschlossen. Bei zwei Patienten mit ausgedehnten Fisteln zum Sinus transversus wurden nach primärer endovaskulärer Therapie einmal eine gute Besserung und einmal keine Veränderung des Zustandes erzielt. Im ersten Falle wurde ein endgültiger Verschluss eines Fistelrestes abgelehnt, bei dem zweiten Patienten kamen weitere Maßnahmen nicht mehr in Betracht.

Abstract

Seven patients presented with intracranial hemorrhage due to arteriovenous dural fistula. Six patients showed intracerebral hemorraghe combined with subdural hematoma and intraventricular hemorrhage in one case respectively, and one patient had infratentorial subarachnoid hemorrhage. Location of the fistulae was frontobasal (n=2), tentorium (n=2), transverse sinus (n=2), and superior sagittal sinus (n=1). Angiography revealed reflux into cortical veins in all cases. Therapy was surgery in both cases with fistula of the anterior cranial fossa with good results. An endovascular intraarterial therapy was performed in a case with cirumscribed fistula of the superior sagittal sinus, this patient developed a second dural fistula during follow-up. Two patients with tentorial fistulae had primary endovascular treatment complicated by infarction of both thalami in one case and a recurrence of the fistula in the other. In the last case the fistula was closed by surgery. Out of two patients with widespread fistulae of the transverse sinus one made a good clinical revovery and the other remained unchanged. In the first case definite closure of a remnant of the fistula was refused, in the second no further therapy was recommended.

Durafistel - intrakranielle Blutung - chirurgische Therapie - endovaskuläre Therapie

Dural arteriovenous fistula - intracranial hemorrhage - surgery - endovascular therapy

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