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      Cavernous Sinus Dural Arteriovenous Fistula Patients Presenting With Headache as an Initial Symptom

      case-report

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          Abstract

          Cavernous sinus (CS) dural arteriovenous fistula (dAVF) patients presenting with only headache as an initial symptom are not common. Patients with CS-dAVF commonly present with symptoms related to their eyes. In all three patients, headache was the initial symptom. Other symptoms related to the eyes developed 1 - 7 months after headache. In one patient, headache was controlled by sumatriptan succinate, but not diclofenac sodium or loxoprofen sodium. In another patient, headache was controlled by loxoprofen sodium. In the third patient, headache was improved by stellate ganglion block. In all patients, magnetic resonance angiography (MRA) in the early stage of the clinical course showed abnormal blood flow in the CS. However, reflux to the superior ophthalmic vein (SOV) was not detected. As treatment, transarterial and transvenous embolizations were necessary for one patient, and transvenous embolization was performed for another patient with significant blood flow to the SOV and cortical veins. On the other hand, manual compression of the bilateral carotid arteries at the neck resulted in disappearance of the fistula in the third patient. In all patients, the symptoms improved after the disappearance of blood reflux to the CS. The refluxed blood to the CS might cause elevation of the CS pressure and stimulate the trigeminal nerve in the dural membrane, resulting in headache before developing reflux in an anterior direction. CS-dAVF could induce both migraine and common headache. In cases with blood reflux to the CS on magnetic resonance imaging and/or MRA even without eye symptoms, a differential diagnosis of CS-dAVF should be taken into consideration.

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          Most cited references8

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          Nerve block for the treatment of headaches and cranial neuralgias - a practical approach.

          Several studies have presented evidence that blocking peripheral nerves is effective for the treatment of some headaches and cranial neuralgias, resulting in reduction of the frequency, intensity, and duration of pain.
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            Painful oculomotor palsy caused by posterior-draining dural carotid cavernous fistulas.

            Carotid cavernous fistulas cause conjunctival hyperemia and orbital soft-tissue swelling because of increased flow directed anteriorly in ophthalmic veins. Less well recognized is that when fistular flow is directed posteriorly, these congestive features will be absent and the diagnosis of the "white-eyed shunt" will be missed unless angiography is performed. Two patients who had oculomotor nerve palsies caused by posteriorly draining dural carotid cavernous fistulas were studied, and the 28 previously described cases were reviewed. One patient had a chronic painful palsy of the sixth cranial nerve, and the other, a palsy of the third cranial nerve. Cerebral angiography disclosed the fistulas. The clinical and imaging features of these cases conform to those of the 28 previously reported white-eyed shunts. Angiographic features do not explain why some posterior-draining fistulas cause sixth-nerve palsies and others cause third- (or rarely, fourth-) nerve palsies. Dural carotid cavernous fistulas that drain primarily into the inferior petrosal sinus may cause painful oculomotor palsies that elude diagnosis because they lack congestive orbito-ocular features. Treatment by embolization leads to more rapid resolution of manifestations.
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              A migraine-like headache induced by carotid-cavernous fistula.

              Carotid-cavernous fistula (CCF) generally causes periorbital aching with ocular symptoms due to high venous pressure in the cavernous sinus, while migraine is caused by arterial dilatation-stimulating trigeminal nerves around the vessels. The authors present a case of 47-year-old woman with a 4-month history of a temporal throbbing headache. As her symptoms were well controlled by triptans, her headache was considered to be migraine in type. However, a Barrow's type-D CCF was revealed by radiological examinations. Self-compression of common carotid artery method was initially tried for therapy of the CCF, but endovascular embolization was finally necessary due to intractable headache. Although the headache was considered arterial in origin, transvenous embolization of the left cavernous sinus successfully ameliorated the patient's symptoms. CCF should be considered as an unusual etiology of headaches that appear arterial in origin.
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                Author and article information

                Journal
                J Clin Med Res
                J Clin Med Res
                Elmer Press
                Journal of Clinical Medicine Research
                Elmer Press
                1918-3003
                1918-3011
                April 2016
                27 February 2016
                : 8
                : 4
                : 342-345
                Affiliations
                [a ]Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
                [b ]Department of Neurology, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
                [c ]Department of Neurosurgery, Shima Neurosurgical and Orthopedic Clinic, Kawasaki, Japan
                [d ]Department of Neurosurgery, Taguchi Neurosurgery Clinic, Yokohama, Japan
                Author notes
                [e ]Corresponding Author: Motohiro Nomura, Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581, Japan. Email: nomura413jp@ 123456yahoo.co.jp
                Article
                10.14740/jocmr2489w
                4780500
                26985257
                933c4144-afd9-41db-8f80-2f4e5192dda8
                Copyright 2016, Nomura et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 10 February 2016
                Categories
                Case Report

                Medicine
                headache,migraine,dural arteriovenous fistula,cavernous sinus
                Medicine
                headache, migraine, dural arteriovenous fistula, cavernous sinus

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