Neurocirugía (English edition) Neurocirugía (English edition)
Neurocirugia 2004;15:458-67 - Vol. 15 Num.5 DOI: 10.1016/S1130-1473(04)70458-3
Unruptured dural arteriovenous malformation of the transverse-sigmoid sinus presenting with focal symptoms and coma
Malformación arteriovenosa dural del seno transverso-sigmoide no sangrante manifestada por síntomas focales y coma
J.C. Palomino??, R.D. Lobato, J. Campollo, J. Fernández-Alen, A. Lagares
Service of Neurosurgery and Section of Neuroradiology. Hospital “12 de Octubre”. Faculty of Medicine. University Complutense. Madrid
Received 06 November 2003, Accepted 02 January 2004

We are presenting the case of a 63 year-old man with a dural arteriovenous malformation of the transverse sigmoid sinus who developed focal deficits followed by less localized symptoms such a disorientation, lethargy and eventually comatose status. Initial cerebral angiography showed retrograde filling of the cortical and deep cerebral venous system with marked delay in venous empting. Following embolization clinical symptoms completely cleared at the time that control angiography showed retrograde venous flow turning anterograde. Patient's symptoms recurred four months later when there was a relapse of retrograde cerebral venous drainage at the time he developed thrombosis of the superior longitudinal and right transverse sinuses. Sinus thrombosis and thrombosis of the central retinal artery were coincidental with hypercoagulability rela-ted to hyperhomocysteinemia. Since control angiography still showed persistence of the AV shunting radical excision of the involved dural sinuses was performed. The final outcome was excellent.

The physiopathological mechanism responsible for neurological deficits in our patient most likely was ischemia of venous origin secondary to venous hyper-tension resulting from retrograde cerebral venous drainage. The clinical and angiographic presenta-tion in few similar cases reported in the literature is reviewed.


Se presenta el caso de un hombre de 63 años con una malformación arteriovenosa dural de la región del seno transverso-sigmoide que debutó con síntomas focales para desarrollar después déficit de funciones superiores y finalmente estupor y coma. La angiografía cerebral inicial mostró drenaje venoso retrogrado hacia venas cerebrales corticales y profundas con un marcado retardo del tiempo angiográfico. Tras la práctica de embolización transarterial los síntomas revirtieron por completo, al tiempo que la angiografia de control mostró una normalización del drenaje venoso que se hizo anterógrado. Cuatro meses después los síntomas recurrieron coincidiendo con la reaparición de drenaje venoso cerebral retrógrado cuando el paciente presentó trombosis del seno longitudinal superior, del seno transverso-sigmoide derecho y de la arteria central de la retina en el contexto de hipercoagulabilidad secundaria a hiperhomocisteinemia. La angiografía cerebral de control mostró persistencia de fístula AV y drenaje venoso retrógrado por lo que se procedió a resecar las estructuras durales implicadas, logrando la curación definitiva.

El mecanismo fisiopatológico responsable de los síntomas en nuestro paciente fue probablemente isquémico de origen venoso secundaria a la hipertensión del sector venoso causada por la fistula AV dural. Se revisa la presentación clínica y angiográfica en casos similares reportados en la literatura.

Palabras clave
Malformación arteriovenosa, Fístula dural arteriovenosa, Seno venoso, Isquemia, Presión intracraneal, Trombosis, Coma, Embolización, Cirugía, Hiperhomocisteinemia
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Palomino. J.C.; Lobato, R.D.; Campollo, J.; Fernández-Alen, J.; Lagares, A.: Unruptured dural arteriovenous malformation of the transversesigmoid sinus presenting with focal symptoms and coma. Neurocirugía 2004; 15: 458–467.

Correspondencia postal: Servicio de Neurocirugía. Hospital “12 de Octubre”. Avda de Córdoba, s/n. 28041 Madrid. (J.C. Palomino )
Copyright © 2004. Sociedad Española de Neurocirugía
Neurocirugia 2004;15:458-67 - Vol. 15 Num.5 DOI: 10.1016/S1130-1473(04)70458-3