Cavernous sinus dural arteriovenous malformations: patterns of venous drainage are related to clinical signs and symptoms.
OBJECTIVE
To provide evidence that venous congestion and drainage patterns are responsible for the manifestations of cavernous sinus area dural arteriovenous malformations (CSdAVMs).


METHODS
Retrospective observational case series.


METHODS
Records of 85 patients with complete clinical and angiographic evaluations of CSdAVMs were evaluated for the clinical features of the disorder. A neuroradiologist analyzed patterns of venous drainage to and from the cavernous sinus without knowledge of the clinical features. Four venous drainage patterns (reversal of flow from the CSdAVMs into the anterior cavernous sinus, ophthalmic vein thrombosis, drainage into the inferior petrosal sinus or drainage into the superior petrosal sinus) were statistically tested for their predictive value of signs and symptoms using logistic regression.


METHODS
The power of prediction of orbital congestion, elevated IOP, extraocular muscle dysfunction, optic neuropathy, venous-stasis retinopathy, choroidal effusion, anterior chamber shallowing, bruits, cranial nerve paresis, and central nervous system dysfunction from four patterns of venous drainage.


RESULTS
Reversal of drainage into the anterior cavernous sinus and ophthalmic veins was highly predictive (P = 0) of orbital congestion, which was seen in 77 (91%) patients. In contrast, eight (9%) patients without orbital congestion had shunts that did not drain into the anterior cavernous sinus and ophthalmic veins. Cavernous sinus dural arteriovenous malformation drainage into the anterior cavernous sinus and ophthalmic veins also predicted elevated IOP (P = 0.0023) and optic neuropathy (P = 0.047). Ophthalmic vein thrombosis significantly predicted cases with choroidal effusion (P = 0.002) and anterior chamber shallowing (P = 0.01). Third nerve paresis could be predicted from flow toward the inferior petrosal sinuses (P = 0.017). Central nervous system symptoms or dysfunction, occurring in 7 (8%) patients, was predicted by venous drainage into the superior petrosal sinus (P = 0.0008).


CONCLUSIONS
The clinical features found in patients with CSdVAMs are related to the abnormal venous drainage and can be predicted by these venous drainage patterns. Venous congestion and hypertension seem to cause the clinical dysfunction in this disorder.
Neuro-Ophthalmology Service, Department of Ophthalmology, Rabin Medical Center, Petah Tikva, Israel.
Hadas
H
Stiebel-Kalish
Avi
A
Setton
Yassunari
Y
Nimii
Yuval
Y
Kalish
Jonathan
J
Hartman
Ruth
R
Huna Bar-On
Alejandro
A
Berenstein
Mark J
MJ
Kupersmith
D000368:Aged; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D002426:Cavernous Sinus / Q000473:pathology*; D002533:Cerebral Angiography; D002540:Cerebral Cortex / Q000473:pathology; D002550:Cerebral Veins / Q000000981:diagnostic imaging / Q000473:pathology*; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D009916:Orbital Diseases / Q000175:diagnosis; D012189:Retrospective Studies