- 期刊
少見以眼窩及鼻旁顏面部脹痛為初始表現之頸動脈海綿竇瘻管－病例報告
Carotid-cavernous Sinus Fistula with Initial Presentation as Periorbital, Paranasal and Maxillary Pain and Pressure-Case Report
摘要
頸動脈海綿竇瘻管（carotid-cavernous sinus fistula）為頸動脈系統之血管與靜脈系統的海綿竇有不正常連通道。依病因可分為自發性及外傷性。外傷性多為因重力撞擊導致顱底骨折進而影響動靜脈系統；其他原因為顱內動脈瘤（intracranial aneurysm）病史、靜脈血栓、血管粥狀硬化、高血壓及基因導致血管壁缺損等。本篇報告為一45歲女性有鼻過敏、高血壓及高血脂病史。病人起初以右側頭痛、右鼻部周圍（上頷竇顏面區）脹痛及右側眼窩疼痛約10天。其先至眼科診所後至本院家醫科及神經內科求診，因鼻部周圍脹痛合併鼻分泌物（鼻竇症狀），懷疑鼻竇炎被轉至耳鼻喉科，但經內視鏡檢及影像學檢查結果並非鼻竇炎所引起，先給予藥物症狀治療並持續追蹤。病人於回診時主述頭痛症狀加劇及複視的情況發生，理學檢查發現新發生之眼皮下垂，進一步安排腦部磁振血管造影（MRA）與血管攝影檢查（angiography），最後診斷為右側間接型頸動脈海綿竇瘻管（right indirect caroticocavernous fistula），經血管內介入處置（栓塞治療）後情況改善。由於過往的經驗，頸動脈海綿竇瘻管常見症狀為搏動性眼球突出（pulsatile exophthalmos）、結膜水腫充血（chemosis）、眼部紊流聲（ocular bruit），又稱頸動脈海綿竇瘻管典型表徵（Dandy's triad）。此案例初始症狀表現為頭痛及鼻旁顏面部周圍脹痛相對少見。最後，臨床上頭痛合併眼鼻部症狀除了排除常見的鼻竇炎及其併發症、偏頭痛及三叉神經痛等之外，還需將頸動脈海綿竇瘻管列入鑑別診斷之中，希望能盡早發現治療，以減少後續嚴重併發症的發生。
並列摘要
Carotid-cavernous sinus fistula (CCF) is an abnormal communication between the carotid circulation and the cavernous sinus. The causes of CCF can be divided into traumatic and spontaneous. Traumatic CCF may occur after head injuries in which the peri-cavernous carotid artery is torn due to skull base fracture. Spontaneous CCF results from ruptured aneurysm, atherosclerosis, hypertension, collagen vascular disease and so on. This is a rare case of CCF with initial presentation as pain and pressure around eyes and paranasal area, and sinus symptoms including nasal discharge, instead of the classic triad as pulsatile exophthalmos, chemosis, and ocular bruit. Brain MRA and cerebral angiogram revealed right CCF. She received endovascular intervention to treated AV shunts and no residual AVF was found in following image after intervention was done. Headache and paranasal pain with facial fullness improved after endovascular management. Clinically, in patients with headache, ocular and facial fullness, and paranasal symptoms, we should not only considerate sinusitis with its complications, infectious diseases, migraine and trigeminal neuralgia, but also include CCF in the differential diagnosis. Early diagnosis and treatment of CCF can greatly contribute to a decrease in morbidity.