Letter to the Editor
Cluster-tic syndrome as the first clinical manifestation of a dural carotid-cavernous fistula
Clúster-tic como comienzo clínico de una fístula dural carótido cavernosa
M. Payán Ortiz
, P. Guardado Santervás, A. Arjona Padillo, A. Aguilera del Moral
Corresponding author
Unidad de Neurología Clínica y Diagnóstica, Complejo Hospitalario Torrecárdenas, Almería, Spain
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Derecha: Arteriografía de arteria carótida interna derecha en proyección lateral con aporte al seno cavernoso. En ambas imágenes se aprecia que coexiste reflujo a la vena oftálmica derecha y las venas de la cara, y hay extensa participación de venas corticales hemisféricas cerebrales derechas.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Payán Ortiz, P. Guardado Santervás, A. Arjona Padillo, A. Aguilera del Moral" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Payán Ortiz" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Guardado Santervás" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Arjona Padillo" ] 3 => array:2 [ "nombre" => "A." 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Payán Ortiz, P. Guardado Santervás, A. Arjona Padillo, A. Aguilera del Moral" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Payán Ortiz" "email" => array:1 [ 0 => "payanortiz@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Guardado Santervás" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Arjona Padillo" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Aguilera del Moral" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Neurología Clínica y Diagnóstica, Complejo Hospitalario Torrecárdenas, Almería, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Clúster-tic como comienzo clínico de una fístula dural carótido cavernosa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 743 "Ancho" => 1502 "Tamanyo" => 146909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Left</span>: Anteroposterior projection angiogram of the left common carotid artery with blood supply to the cavernous sinus from the internal maxillary artery and the inferolateral trunk of the internal carotid. <span class="elsevierStyleItalic">Right</span>: Left external carotid artery angiogram, lateral projection, with blood supply from the internal maxillary artery to the cavernous sinus.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">According to McCormick's 1966 classification system, cerebral vascular malformations are categorised as arteriovenous malformations, venous malformations, capillary telangiectasias, cavernous angiomas, and varix. Dural arteriovenous fistulas were first described in the 1930s and they are regarded as a separate entity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Dural arteriovenous fistulas account for 10% to 15% of all intracranial arteriovenous lesions and their symptoms and prognosis vary considerably. Some may elicit tinnitus or ocular symptoms, while others may provoke neurological symptoms or intracranial haemorrhage. The Cognard classification is the most widely used to determine the risk associated with dural arteriovenous fistulas in order to make treatment decisions. It rates fistulas in 5 categories, from <span class="elsevierStyleSmallCaps">I</span> to <span class="elsevierStyleSmallCaps">V</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The Cognard classification is based on different factors, including direction of venous drainage, recruitment, and presence or absence of spinal perimedullary venous drainage. Its 5 categories are described as follows. I: located in the main sinus, with antegrade flow; <span class="elsevierStyleSmallCaps">II</span>: in the main sinus, with reflux into the sinus (<span class="elsevierStyleSmallCaps">II</span>a), cortical veins (<span class="elsevierStyleSmallCaps">II</span>b), or both (<span class="elsevierStyleSmallCaps">II</span>a<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>b); <span class="elsevierStyleSmallCaps">III</span>: direct cortical venous drainage without venous ectasia; <span class="elsevierStyleSmallCaps">IV</span>: direct cortical venous drainage with venous ectasia; and <span class="elsevierStyleSmallCaps">V</span>: with spinal perimedullary venous drainage. Ectasia is diagnosed when vessel calibre is greater than 5<span class="elsevierStyleHsp" style=""></span>mm or more than 3 times the normal diameter.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Dural carotid-cavernous fistula is a specific type of dural arteriovenous fistula in which there is abnormal shunting within the cavernous sinus. The cavernous sinus is a vascular network crossed by the intracranial internal carotid artery, which in turn provides various intracranial branches to nerves and to the pituitary gland (meningohypophyseal trunk and inferolateral trunk). The external carotid artery also extends dural branches to the cavernous sinus; these branches anastomose with internal carotid artery branches. The dural arteriovenous fistula gives rise to high-pressure arterial blood entering the low-pressure cavernous venous sinus. This interferes with normal venous drainage of the cavernous sinus and the orbit.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most dural arteriovenous fistulas are acquired (venous sinus thrombosis, surgery, trauma, spontaneous fistula, etc.).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The formation of these fistulas has been associated with rupture of an intracavernous aneurysm, fibromuscular dysplasia,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Ehlers–Danlos syndrome and other collagen vascular diseases, arteriosclerotic vascular disease, pregnancy, etc.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common clinical manifestations are orbital venous hypertension, orbital venous congestion, eye proptosis, chemosis, dyplopia due to cranial nerve impairment (<span class="elsevierStyleSmallCaps">III</span>, <span class="elsevierStyleSmallCaps">IV</span>, and <span class="elsevierStyleSmallCaps">VI</span>), impairment in the first branch of the trigeminal nerve (<span class="elsevierStyleSmallCaps">V</span>-1), vision loss, central retinal vein occlusion, retinopathy, glaucoma, and headache.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We present a case of dural carotid-cavernous fistula that initially presented as an atypical recurrent headache.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient was a 69-year-old woman with a history of vertiginous syndrome and a cholecystectomy. She was examined due to recurrent right-sided hemicranial headache (predominant in the periorbital region) that had been occurring over 4 months. Headaches appeared almost daily, tended to be more intense at night, and occurred in 2 to 4 episodes per day. These episodes lasted from minutes to hours and were generally described as moderate to intense pain that was oppressive and sometimes pulsating. Accompanying symptoms included conjunctival injection ipsilateral to the pain, an uncomfortable sensation (‘grittiness’) in the right eye, and a sensation of fullness in the right nasal region that occasionally coincided with headaches.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Since onset of these headaches, the patient had also been experiencing short attacks of paroxysmal pain lasting less than 60<span class="elsevierStyleHsp" style=""></span>seconds, described as resembling electric shock and located in the upper right dental arch. Episode periodicity varied throughout the day and the pain was described as moderate to intense with no trigger points or other concomitant symptoms.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient had been examined by ophthalmologists and a dentist, and the facial CT and cranial MRI scans that had been performed revealed no significant findings.</p><p id="par0055" class="elsevierStylePara elsevierViewall">She was admitted to the neurology department due to presenting binocular horizontal diplopia in the preceding days. Examination revealed right-sided sixth nerve palsy with no other findings.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A brain MRI and MRI angiography revealed discrete right-sided exophthalmos, changes in signal intensity in the right cavernous sinus, and an increase in right ophthalmic vein calibre that suggested a right dural carotid-cavernous fistula. In light of these findings, we performed left and right cerebral carotid angiographies which revealed extensive dural fistulous connection affecting the right cavernous and coronary sinuses and probably also the medial margin of the left cavernous sinus. There was a prominent arterial supply from branches of both internal maxillary arteries and also from the inferolateral trunks of both internal carotid arteries. Venous drainage for the fistula followed an anterograde pattern towards both inferior petrosal sinuses, which were found to be permeable. This coexisted with intense reflux to the right superior ophthalmic vein and the facial vein, with extensive involvement of veins of the right cerebral cortex (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Based on this evidence, the MR angiography and cerebral angiography pointed to a grade <span class="elsevierStyleSmallCaps">III</span> dural carotid-cavernous fistula (with direct drainage to right-sided cortical veins and no ectasia).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In a second intervention, doctors embolised the cavernous sinus. Subsequent image series of both carotid arteries showed absence of pathological arteriovenous shunting and normalisation of cerebral blood flow in both carotid territories. At 5 months post-intervention, the patient had experienced no further headaches.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Our patient initially presented with a recurrent headache which met criteria for cluster headache. Nevertheless, other data were atypical, such as recent onset in an elderly woman and the association with trigeminal neuralgia with no trigger points or factors. Coexistence of a cluster headache and trigeminal neuralgia was described years ago under the name of cluster tic syndrome. This entity is recognised by the IHS International Headache Classification.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The primary form of this entity was ruled out by the appearance of oculomotor palsy and findings from complementary tests. The literature has described secondary causes of cluster tic syndrome, including basilar artery ectasia or pituitary adenoma.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although the literature does describe dural arteriovenous fistula in association with intermittent headache, we find few descriptions of the clinical characteristics in such cases.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Another noteworthy feature in our case was the fact that the initial brain MRI was normal. On this basis, we advise using MR angiography or a similar technique when studying trigeminal autonomic cephalalgias. This complementary test can be used to identify numerous vascular conditions that are known causes of secondary cluster headaches (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–12</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, when a patient presents an atypical form of trigeminal autonomic headache, doctors must search for a secondary cause. These headaches are often associated with a wide range of entities, some of which may be quite severe.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Payán Ortiz M, Guardado Santervás P, Arjona Padillo A, Aguilera Del Moral A. Clúster-tic como comienzo clínico de una fístula dural carótido cavernosa. Neurología. 2014;29:125–128.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 744 "Ancho" => 1502 "Tamanyo" => 161198 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Left</span>: Right external carotid artery angiogram, lateral projection, with blood supply from the internal maxillary artery to the cavernous sinus. <span class="elsevierStyleItalic">Right</span>: Lateral projection angiogram of the right internal carotid artery showing blood supply to the cavernous sinus. Both images show the co-presence of reflux to the right ophthalmic vein and facial veins, with extensive participation by right-sided cerebral cortical veins.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 743 "Ancho" => 1502 "Tamanyo" => 146909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Left</span>: Anteroposterior projection angiogram of the left common carotid artery with blood supply to the cavernous sinus from the internal maxillary artery and the inferolateral trunk of the internal carotid. <span class="elsevierStyleItalic">Right</span>: Left external carotid artery angiogram, lateral projection, with blood supply from the internal maxillary artery to the cavernous sinus.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post-traumatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post carotid endarterectomy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sphenoid sinus aspergilloma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enucleation of the eye \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cerebral metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sellar region tumours \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prolactinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meningioma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nasopharyngeal carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clival tumour \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventricular xanthoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cervicomedullary infarction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subdural haematoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Septic thrombosis of the cavernous sinus or posterior communicating artery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial temporal arteriovenous fistula \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mesencephalic, parietal, occipital, or temporal arteriovenous malformation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vertebral artery dissecting aneurysm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mycotic aneurysm of the intracavernous carotid \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab465346.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 1 | 6 |
| 2024 October | 45 | 8 | 53 |
| 2024 September | 61 | 14 | 75 |
| 2024 August | 41 | 13 | 54 |
| 2024 July | 30 | 6 | 36 |
| 2024 June | 51 | 14 | 65 |
| 2024 May | 62 | 7 | 69 |
| 2024 April | 37 | 6 | 43 |
| 2024 March | 52 | 2 | 54 |
| 2024 February | 52 | 5 | 57 |
| 2024 January | 49 | 4 | 53 |
| 2023 December | 58 | 20 | 78 |
| 2023 November | 46 | 10 | 56 |
| 2023 October | 54 | 10 | 64 |
| 2023 September | 51 | 7 | 58 |
| 2023 August | 31 | 11 | 42 |
| 2023 July | 49 | 7 | 56 |
| 2023 June | 40 | 3 | 43 |
| 2023 May | 81 | 11 | 92 |
| 2023 April | 55 | 5 | 60 |
| 2023 March | 51 | 1 | 52 |
| 2023 February | 58 | 4 | 62 |
| 2023 January | 62 | 13 | 75 |
| 2022 December | 34 | 5 | 39 |
| 2022 November | 38 | 9 | 47 |
| 2022 October | 29 | 10 | 39 |
| 2022 September | 52 | 8 | 60 |
| 2022 August | 70 | 12 | 82 |
| 2022 July | 30 | 6 | 36 |
| 2022 June | 30 | 5 | 35 |
| 2022 May | 37 | 12 | 49 |
| 2022 April | 32 | 8 | 40 |
| 2022 March | 44 | 5 | 49 |
| 2022 February | 38 | 4 | 42 |
| 2022 January | 57 | 8 | 65 |
| 2021 December | 46 | 20 | 66 |
| 2021 November | 39 | 11 | 50 |
| 2021 October | 67 | 13 | 80 |
| 2021 September | 48 | 17 | 65 |
| 2021 August | 47 | 11 | 58 |
| 2021 July | 47 | 9 | 56 |
| 2021 June | 42 | 16 | 58 |
| 2021 May | 46 | 5 | 51 |
| 2021 April | 93 | 9 | 102 |
| 2021 March | 71 | 14 | 85 |
| 2021 February | 63 | 7 | 70 |
| 2021 January | 61 | 21 | 82 |
| 2020 December | 48 | 21 | 69 |
| 2020 November | 40 | 3 | 43 |
| 2020 October | 35 | 9 | 44 |
| 2020 September | 33 | 8 | 41 |
| 2020 August | 41 | 12 | 53 |
| 2020 July | 30 | 8 | 38 |
| 2020 June | 17 | 2 | 19 |
| 2020 May | 32 | 11 | 43 |
| 2020 April | 26 | 6 | 32 |
| 2020 March | 27 | 11 | 38 |
| 2020 February | 36 | 14 | 50 |
| 2020 January | 28 | 11 | 39 |
| 2019 December | 42 | 8 | 50 |
| 2019 November | 19 | 6 | 25 |
| 2019 October | 26 | 0 | 26 |
| 2019 September | 36 | 5 | 41 |
| 2019 August | 32 | 2 | 34 |
| 2019 July | 58 | 24 | 82 |
| 2019 June | 65 | 21 | 86 |
| 2019 May | 129 | 15 | 144 |
| 2019 April | 49 | 4 | 53 |
| 2019 March | 25 | 2 | 27 |
| 2019 February | 19 | 7 | 26 |
| 2019 January | 23 | 6 | 29 |
| 2018 December | 18 | 2 | 20 |
| 2018 November | 25 | 2 | 27 |
| 2018 October | 40 | 5 | 45 |
| 2018 September | 8 | 9 | 17 |
| 2018 August | 13 | 2 | 15 |
| 2018 July | 12 | 0 | 12 |
| 2018 June | 5 | 3 | 8 |
| 2018 May | 15 | 1 | 16 |
| 2018 April | 18 | 1 | 19 |
| 2018 March | 16 | 11 | 27 |
| 2018 February | 6 | 3 | 9 |
| 2018 January | 12 | 3 | 15 |
| 2017 December | 5 | 1 | 6 |
| 2017 November | 20 | 2 | 22 |
| 2017 October | 16 | 3 | 19 |
| 2017 September | 13 | 2 | 15 |
| 2017 August | 23 | 5 | 28 |
| 2017 July | 16 | 2 | 18 |
| 2017 June | 16 | 6 | 22 |
| 2017 May | 32 | 8 | 40 |
| 2017 April | 23 | 2 | 25 |
| 2017 March | 11 | 17 | 28 |
| 2017 February | 19 | 10 | 29 |
| 2017 January | 19 | 4 | 23 |
| 2016 December | 18 | 9 | 27 |
| 2016 November | 31 | 9 | 40 |
| 2016 October | 49 | 5 | 54 |
| 2016 September | 113 | 7 | 120 |
| 2016 August | 40 | 4 | 44 |
| 2016 July | 23 | 3 | 26 |
| 2016 June | 22 | 6 | 28 |
| 2016 May | 40 | 21 | 61 |
| 2016 April | 21 | 9 | 30 |
| 2016 March | 54 | 21 | 75 |
| 2016 February | 15 | 15 | 30 |
| 2016 January | 17 | 11 | 28 |
| 2015 December | 17 | 6 | 23 |
| 2015 November | 17 | 7 | 24 |
| 2015 October | 27 | 6 | 33 |
| 2015 September | 28 | 6 | 34 |
| 2015 August | 48 | 8 | 56 |
| 2015 July | 40 | 6 | 46 |
| 2015 June | 24 | 0 | 24 |
| 2015 May | 36 | 5 | 41 |
| 2015 April | 34 | 9 | 43 |
| 2015 March | 19 | 8 | 27 |
| 2015 February | 32 | 3 | 35 |
| 2015 January | 31 | 3 | 34 |
| 2014 December | 26 | 11 | 37 |
| 2014 November | 18 | 4 | 22 |
| 2014 October | 27 | 5 | 32 |
| 2014 September | 25 | 4 | 29 |
| 2014 August | 28 | 5 | 33 |
| 2014 July | 24 | 5 | 29 |
| 2014 June | 23 | 6 | 29 |
| 2014 May | 14 | 3 | 17 |
| 2014 April | 21 | 8 | 29 |
| 2014 March | 24 | 11 | 35 |
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