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Show Journal of Neuro- Ophthalmology 18( 1): 49- 52, 1998. © 1998 Lippincolt- Raven Publishers, Philadelphia Papilledema in a Man with an " Occult" Dural Arteriovenous Malformation Timothy J. Martin, M. D., D. Antonio Bell, M. D., John A. Wilson, M. D. CASE REPORT A 51- year- old man was evaluated in November 1994 for transient visual obscurations for 2 months. In addition, he reported hearing his " heartbeat" in both ears. He denied headache, vitamin use, recent trauma, or recent weight gain or loss. Visual acuity was 20/ 15 in each eye, with no relative afferent pupillary defect, normal motility, and normal slit- lamp examination results. Automated perimetry showed mild enlargement of the blind af> ( Si • ' & * " a * " - ( * M £ H ) h- jjjggj- j " < 5> * t! i) t!) ^ fclTr MO * 87 ( JB P < 2X CPSO' 000 < fB left eye FW* tonLocn>: 0/ 17 F t fM POSEim.; 0 / 5 F « S* tea Enors. o/ e TniOurMwv 08.53 I ' M ) 31 dO B right eye ( II) ( W> ' • & " " • & » " a » » » » - A-** £- a • " » * ft » > ti^- fe^ 4^> » „ 1F W> 2 1 5 ( 6 P30 3 8 * dB P< 5X S- 193 tfB 0> SP: 3, ia 00 P< ZX Fk4tOoLot » *. i / 1B rusePOSCrtMtrl/ tl Tot CwMttv 0909 » • » & * hg-& " f » left eye FIG. 1. Humphrey automated 30- 2 perimetry. $ - » =, e I a K x c P » . « . I 9 03 " < 5X right eye Manuscript received April 25, 1997; accepted July 25, 1997. From the Departments of Ophthalmology ( T. J. M.), Radiology ( D. A. B.), and Neurosurgery ( J. A. W.), Bowman Gray School of MedicineAVake Forest University, Winston- Salem, North Carolina, U. S. A. Address correspondence and reprint requests to Dr. Timothy J. Martin, Wake Forest University Eye Center, Medical Center Boulevard, Winston- Salem, NC 27157- 1033, U. S. A. Presented as a poster at the North American Neuro- Ophthalmology Society meeting in Keystone, Colorado, February 10, 1997. 49 50 T. J. MARTIN ET AL. spots and scattered threshold loss in the inferior nasal quadrants ( Fig. 1A). Bilateral diffuse optic disk edema was present ( Fig. 2A). Enhanced magnetic resonance imaging ( MRI) of the brain was read as normal. A lumbar puncture showed an opening pressure of 300 mm of water with normal cerebrospinal fluid ( CSF). Acetazol-amide ( 500 mg twice a day) was started. By March 1995 the patient noted increased intensity of the pulsatile tinnitus. The examination was unchanged except that a cranial bruit could now be auscultated over the left retroauricular area. Cerebral angiography confirmed the presence of a suspected dural arteriovenous malformation ( DAVM) in the region of the left transverse sinus ( Fig. 3). In retrospect, evidence of the DAVM could be identified on the original MRI ( Fig. 4). Transarterial particulate embolization was performed and resulted in rapid abatement of the patient's symptoms. Acetazolamide was discontinued. In May the patient's pulsatile tinnitus returned, although it was less prominent. The visual fields suggested improvement ( Fig. IB), but the papilledema was only minimally improved ( Fig. 2B). Opening pressure on lumber puncture was 410 mm of water. Angiography was repeated in July, showing recanali-zation of the DAVM and occlusion of the left sigmoid sinus at the skull base ( Fig. 5). Venous pressures in the superior sagittal sinus ( SSS) and left transverse sinus were markedly elevated ( 33 mmHg in the left transverse sinus; 26 mmHg in the SSS). Transarterial embolization of the DAVM with acrylic glue was performed with incomplete closure and only temporary relief of symptoms. The pulsatile tinnitus recurred in November, and an- /" right \ November. V 7 left , Pf f% • • • > * l e r t^ FIG. 2. Optic disk appearance. ./ Neum- Ophlhalmol, Vol. 18, No. 1, 1998 OCCULT DURAL ARTERIOVENOUS MALFORMATION 51 r J FIG. 3. Angiography ( lateral projection of common carotid artery injection) shows the DAVM ( arrows), fed by numerous branches of the external carotid artery, and meningeal branches of the internal carotid artery. giography identified persistent feeding arteries. A trans-venous approach allowed successful closure of the left transverse and sigmoid sinuses with multiple fibered platinum coils ( Fig. 6). Within 2 months there was clear FIG. 4. Axial MRI. The MRI was initially interpreted as normal. In retrospect, the irregular contour and flow voids in the left transverse sinus reflect the presence of the DAVM ( arrows). * W^ T J . k ^ i Ik / V6i FIG. 5. Angiography ( left internal jugular injection) shows inability to inject contrast beyond the skull base ( arrow), demonstrating sigmoid sinus occlusion. improvement in the patient's optic disk edema ( Fig. 1C), and the patient has remained asymptomatic for over a year. DISCUSSION The syndrome of idiopathic intracranial hypertension in obese women is a well- described primary entity. However, in men with papilledema, a diligent search for an identifiable cause must be pursued. MRI alone may not be sensitive enough to visualize DAVMs ( 1). It is unknown whether magnetic resonance angiography and venography ( MRA and MRV) would have been diagnostic in this case, because auscultation of an intracranial bruit r FIG. 6. Angiography ( lateral projection of common carotid artery injection) shows coils in the sigmoid and transverse sinuses ( arrows) and successful closure of the DAVM. J Neuro- Ophlhalmol, Vol. IS, No. I, 1998 52 T. J. MARTIN ETAL. led directly to cerebral angiography. The possibility of a dural sinus abnormality suggests that it is reasonable to include MRA and MRV sequences with the initial MRI evaluation of men with papilledema ( and women with atypical presentations). However, angiography remains the standard and must be pursued when clinically indicated, even with normal noninvasive imaging ( 1- 3). Acknowledgment: Photographs and images were prepared by Richard E. Hackel, M. A., C. R. A. REFERENCES 1. Bianchi- Marzoli S, Righi C, Brancato R, et al. Pseudotumor cerebri in men: the need for cerebral angiography. In the proceedings of the North American Neuro- ophthalmology Society Durango, Colorado, 1994. 2. Halbach VV, Higashida RT, Hieshima GB, et al. Dural fistulas involving the transverse and sigmoid sinuses: results of treatment in 28 patients. Radiology 1987; 163: 443- 7. 3. Kupersmith, MJ. Neuro- ophthalmic manifestations of intracranial dural venous disorders. In: Kupersmith MJ, ed. Neuro- vascular Neuro- ophthalmology. Berlin: Springer- Verlag, 1993. J Neiiro- Ophthalinol, Vol. IS, No. 1, 1998 |
