血管内栓塞治疗脑动静脉畸形（附23例分析）

目的：分析报告23例经血管内栓塞治疗的脑动静脉畸形。材料和方法：23例脑动静脉畸形，11例有癫痫发作史，9例蛛网膜下胜或脑内出血，5例有神经功能障碍、头痛，2例有颅内杂音。畸形团小于3cm2例，3一6cm15例，，大于6cm6例。应用Magic导管系统经股动脉行脑动静脉畸形超选择栓塞，应用NBCA或IBCA16例，线段5例，IBCA和线段2例。结果：畸形血管团栓塞90％以上9例，70—90％10例，小于50％4例，3例栓塞后行手术切除。痊愈10例，改善10例，2例有神经功能障碍，1例死亡。结论：栓塞治疗加手术切除是治疗较大的、高血流量、功能区脑动静脉畸形的较好方法。NBCA或IBCA是安全有效的栓塞材料。     

脑动静脉畸形的X刀治疗

目的　探讨立体定向放射外科治疗脑动静脉畸形的临床效果。方法　对 87例脑动静脉畸形患者采用X刀治疗 ,畸形团大小大小 5～ 4 0mm。单独接受X刀治疗 5 5例 ,联合血管内栓塞治疗32例。治疗周边剂量 17～ 30Gy ,平均 2 2 .6Gy ,等剂量曲线 70 %～ 90 %。随访时间 6～ 96个月 ,平均 5 3.4个月。结果　单独应用X刀治疗的脑动静脉畸形患者 ,完全闭塞 4 1例 ,部分闭塞 9例 ,无变化 5例 ;联合血管内栓塞治疗患者 ,完全闭塞 2 6例 ,部分闭塞 3例 ,无变化 3例。全组完全闭塞 6 7例 (77.0 % )。癫痫完全缓解 7例 (2 6 .2 % ) ,头痛头昏症状缓解 18例 (38.3% )。并发症 :再出血 2例 ,症状性放射性脑水肿 6例 ,经治疗后 ,完全缓解 2例 ,遗留神经功能障碍 4例。结论　立体定向放射外科是脑动静脉畸形的安全而有效的治疗方法之一。     

Onyx-18栓塞治疗脑动静脉畸形28例临床分析

目的 介绍应用Onyx-18栓塞治疗脑动静脉畸形的体会.方法 采用Onyx-18对28例脑动静脉畸形患者进行栓塞治疗.结果 28例患者中,畸形血管团栓塞80%以上4例,其中2例达到影像学完全栓塞(血管造影动、静脉期均无畸形血管团显影),栓塞范围50% ～ 80% 20例,50%以下4例.28例中5例患者于术中或术后出现...     

ONYX在脑血管畸形治疗中的应用

目的　报告采用液态栓塞材料 (Onyx)栓塞治疗脑动静脉畸形的初步经验。方法　采用Onyx对 17例脑动静脉畸形进行血管内栓塞治疗 ,其中 1例选择 3支血管栓塞 ,9例选择 2支血管栓塞 ,7例选择 1支血管栓塞 ,注胶时间 10～ 70min。结果　即可影像结果 :10 0 %栓塞 5例 ,70 %以上 5例 ,70 %以下 7例。并发症 :术后出血 2例 ,微导管不能拔除 1例。结论　ONYX栓塞脑动静脉畸形与NBCA相比具有在畸形团内弥散好、注胶时间长、一次栓塞的畸形团多和安全性高等优点 ,但需要进一步积累经验 ,提高疗效。     

经导管血管内栓塞术治疗肢体动静脉畸形（附6例分析）

目的:评价先天性肢体动静脉畸形血管内栓塞治疗的有效性和安全性.材料和方法:6例临床诊断为肢体动静脉畸形的患者,常规行患肢动脉DSA检查,对动静脉瘘(AVF)和畸形血管团分别超选择动脉内栓塞治疗,AVF选用弹簧圈,畸形血管团用无水酒精或平阳霉素碘化油乳剂栓塞.结果:超选择动脉栓塞技术均成功,6例患者栓塞后血管异常杂音及临床症状消除.随访6～13个月6例患者均无严重并发症发生.结论:动脉DSA检查是诊断先天性肢体动静脉畸形最有效方法,而血管内栓塞术是安全有效的微创治疗方法.     

Onyx栓塞治疗脑中央区动静脉畸形

目的探讨Onyx胶栓塞治疗脑中央区动静脉畸形的效果。方法选择18例脑中央区动静脉畸形患者,按Drake标准分为小型10例、中型6例、大型2例,应用Onyx胶共行24次血管内栓塞治疗。结果经治疗后,完全栓塞12例（66.7%）,致残（症状较术前加重）2例（11.1%）,其中中型组完全栓塞3例（50%）,与小型组完全栓塞9例（90%）比较差异有统计学意义（P〈0.05）,无死亡病例。供血动脉长度大于2cm与小于2cm完全栓塞比较差异有统计学意义（P〈0.05）。结论Onyx胶栓塞治疗脑中央区动静脉畸形安全有效,畸形团大小和供血动脉长度对完全栓塞率有一定影响。     

ONYX胶栓塞治疗颅内动静脉畸形的临床应用

目的:探讨应用Onyx胶栓塞治疗颅内动静脉畸形的应用价值。方法:全麻下经股动脉穿刺插管,微导管超选择插管到达病变部位后,用Onyx栓塞治疗颅内动静脉畸形30例。结果:30例颅内动静脉畸形患者,共行47次栓塞治疗,畸形血管团栓塞达80%以上者8例,其中4例完全栓塞,栓塞50%~80%者15例,栓塞50%以下者7例。发生颅内出血并发症2例,球麻痹1例,经过相应处理后好转。结论:Onyx是治疗脑动静脉畸形较为理想的栓塞材料,血管内栓塞是颅内动静脉畸形综合治疗中重要的组成部分。     

α-氰基丙酸正丁酯血管内栓塞治疗脑动静脉畸形的临床研究

 目的探讨脑动静脉畸形(AVMs)的血管内栓塞治疗.方法回顾性地分析195例AVMs患者的血管内栓塞治疗过程.结果血管内栓塞治疗159例,297次,治疗后临床症状消失,完全恢复正常生活、工作者32例(20%),临床症状明显好转123例(77.4%).结论血管内栓塞治疗是一种AVMs首选并且有效的治疗方法,尤其对于终末型供血者.     

眼眶血管畸形介入硬化栓塞治疗的临床观察

目的探讨介入硬化栓塞治疗眼眶血管畸形的方法,评价其临床疗效及安全性。 方法回顾性分析2013年1月至2019年1月在我院收治的46例眼眶血管畸形患者（包括静脉畸形、动静脉畸形）的临床资料,其中静脉畸形33例,动静脉畸形13例。静脉畸形治疗均为经皮局部硬化治疗（药物为聚多卡醇/无水乙醇）,动静脉畸形以经导管动脉硬化栓塞（栓塞剂为弹簧圈）及经皮局部硬化（药物为聚多卡醇/无水乙醇）联合治疗。随访时间15～57个月（中位随访时间35个月）。 结果33例静脉畸形接受局部硬化治疗次数2～5次（平均3.5次）,13例动静脉畸形接受介入治疗次数2～6次（平均3.9次）。33例静脉畸形至随访期结束时,13例治愈、11例症状明显缓解、9例部分缓解。13例动静脉畸形至随访期结束时,5例自觉血管搏动消失或明显缓解、8例眶周肿胀较前缓解。所有患者均有术后一过性眶周肿胀,未发生眶周皮肤破溃、视力衰退、眼球萎缩及异位栓塞等严重并发症。 结论眼眶血管畸形行介入治疗安全,可以有效地缓解眶周症状。     

脑动静脉畸形供血方式与栓塞的关系研究

目的探讨脑动静脉畸形供血方式与栓塞的关系。方法回顾性分析12 4例4 0 0次超选择性微导管造影所显示的脑动静脉畸形的供血方式及其栓塞后并发症的发生率。结果4 0 0次微导管超选择性造影显示终末型供血方式2 92次,占73% ,穿枝型供血方式2 8次,占7% ,动静脉直接交通型36次,占9%。畸形血管团内伴有动脉瘤2 4例,占6 %。畸形血管团内含有静脉瘤或引流静脉呈瘤样扩张者2 0例,占5 %。除穿枝型供血方式16例未行栓塞外,余者栓塞后无严重并发症发生。结论了解脑动静脉畸形供血方式便可知道能否安全的进行栓塞,而测定脑动静脉畸形的动静脉循环时间可指导栓塞用胶的配制浓度。     

Venous congestion: an MR finding in dural arteriovenous malformations with cortical venous drainage.

PURPOSETo present the MR findings of intracranial dural arteriovenous malformations with cortical venous drainage, emphasizing the parenchymal changes.METHODSConventional MR and x-ray angiograms in 13 patients with dural arteriovenous malformations and cortical venous reflux were reviewed. The site of the shunt, location of the venous reflux, and presence of venous stenosis were assessed on the angiograms. Parenchymal changes, dilated vessels, and venous occlusive disease were assessed on MR.RESULTSOn MR, 10 of the 13 patients (77%) had dilated pial vessels. Two patients had hydrocephalus. Two patients presented with parenchymal bleeds, one with a subdural component, both remote from the nidus. Two patients presented with subarachnoid hemorrhage. One patient had a parenchymal bleed 9 months after presentation. Venous occlusion was evident on MR in 2 patients. Diffuse white matter edema in the cerebellar or cerebral hemispheres was present on MR in 4 patients and correlated with neurologic deficits. In 2 of these 4 patients, gadolinium enhancement was seen in the periphery of the involved hemisphere.CONCLUSIONSOn MR a surplus of pial vessels suggests a dural arteriovenous malformation with cortical venous drainage. The MR finding of white matter edema deep in the cerebral or cerebellar hemispheres is direct evidence of a venous congestion.     

Intracranial vascular anomalies in patients with periorbital lymphatic and lymphaticovenous malformations

BACKGROUND AND PURPOSE: The purpose of this study was to determine the nature, incidence, and radiologic appearance of intracranial vascular anomalies that occur in association with periorbital lymphatic malformation (LM) and lymphaticovenous malformation (LVM). MATERIALS AND METHODS: We retrospectively reviewed clinical records and imaging studies of 33 patients ranging in age from the neonatal period to 39 years (mean age, 5.1 years; median age, 1.0 year) who were evaluated for orbital LM or LVM at our institution between 1953 and 2002. Imaging studies, including CT, MR imaging, and cerebral angiograms, were evaluated by 2 radiologists to determine morphologic features of orbital LM and to identify associated noncontiguous intracranial vascular and parenchymal anomalies, including arteriovenous malformations (AVM), cerebral cavernous malformations (CCM), developmental venous anomalies (DVA), dural arteriovenous malformations (DAVM), and sinus pericranii (SP). RESULTS: The malformation was left-sided in 70% of patients. Twenty-two patients (70%) had intracranial vascular anomalies: DVA (n = 20; 61%), CCM (n = 2; 6%), DAVM (n = 4; 12%), pial AVM (n = 1; 3%), and SP (n = 1; 3%). Arterial shunts were present in the soft tissues in 2 patients (6%). Three patients had jugular venous anomalies. Three patients (9%) had cerebral hemiatrophy, 2 (6%) had focal cerebral atrophy, and 2 had Chiari I malformation. CONCLUSIONS: Intracranial vascular anomalies, some of which are potentially symptomatic and require treatment, are present in more than two thirds of patients with periorbital LM. Initial imaging of patients with orbital LM should include the brain as well as the orbit.     

Occlusion of cerebral arteriovenous malformations with N-butyl cyano-acrylate is permanent.

PURPOSETo verify the permanence of total occlusion of cerebral arteriovenous malformations after embolization with N-butyl cyano-acrylate and to evaluate the occlusion rate.METHODSOne hundred thirty-four patients were treated for cerebral arteriovenous malformations with N-butyl cyano-acrylate embolization after superselective catheterization. Those initially totally occluded have been followed with angiography.RESULTSIn 15 instances (11.2%) the arteriovenous malformations were totally occluded by embolization alone. Follow-up angiograms have been performed in 12 cases (80%) after 4 to 78 (mean, 27) months after embolization. In all instances the arteriovenous malformations have remained occluded, and there have been no clinical signs of activity.CONCLUSIONAfter total occlusion of a cerebral arteriovenous malformation with N-butyl cyano-acrylate, the lesion stays occluded, and the clinical course seems stable.     

Aneurysms related to cerebral arteriovenous malformations: superselective angiographic assessment in 58 patients.

PURPOSETo report the comprehensive superselective angiographic characteristics of aneurysms associated with cerebral arteriovenous malformations.METHODOne hundred consecutive patients referred for cerebral arteriovenous malformation embolization underwent preembolization superselective angiography. Superselective angiograms were obtained after microcatheterization of arteriovenous malformation pedicles, and assessed for number and location of aneurysms related to the malformation. A chi 2 test was conducted to correlate these parameters with the onset of intracranial hemorrhage.RESULTSAneurysms were demonstrated in 58 of 100 patients. Single aneurysms were found in 24 patients and multiple aneurysms in 34. Presence and number of aneurysms were found to correlate significantly with a clinical presentation of hemorrhage.CONCLUSIONSuperselective angiography was found to be of paramount importance in elucidating the precise and detailed angioarchitecture of brain arteriovenous malformations.     

Transarterial embolization of cerebral arteriovenous malformations: improvement of results with experience.

PURPOSETo present the treatment outcome after embolization of arteriovenous malformations.METHODSAll patients with cerebral arteriovenous malformations treated in 1987 and 1988 (27 patients, group I) and in 1992 and 1993 (35 patients, group II) were compared regarding treatment results and clinical outcome.RESULTSComplications of the treatment occurred in 52% of group I and 22% of group II patients. Severe complications occurred in 11 % and 0%, respectively. There were no treatment deaths. Thirty percent of the arteriovenous malformations in the first group were totally occluded or made accessible for gamma knife treatment, compared with 69% of the arteriovenous malformations in the second group. The clinical outcome improved from 56% with an excellent or good outcome in group I, to 89% in group II. The follow-up time is much shorter in group II, 1.5 versus 5.5 years in group I.CONCLUSIONA definite improvement in treatment outcome has been achieved. The clinical outcome seems to have improved as well, although the shorter follow-up time makes this conclusion less certain.     

New developments in MRA: time-resolved MRA

For many clinical questions, less invasive angiography methods have at least in part already replaced digital subtraction angiography (DSA) as a routine diagnostic procedure. However, temporal resolution achievable with DSA is still indispensable in some patients. Recent advances in MR hardware performance and imaging techniques permit sub-second frame rate MR angiographies to be performed using a rapidly repeated fast T1 weighted gradient echo sequence during administration of a contrast bolus, and subsequent complex subtraction in k-space to emphasise the difference in phase between stationary tissue and contrast-enhanced blood. This technique allows two-dimensional projection angiograms to be obtained at a temporal frame rate of three images per second and with a spatial in-plane resolution of about one square millimetre. This time-resolved information is important for (a) the detection and follow-up of arteriovenous malformations, including their arterial feeders, the size of the nidus and their venous drainage patterns, (b) the demonstration of dural arteriovenous fistulas, recognised as an early filling of a dural sinus during the early arterial phase, and (c) the characterization of the vascularisation of brain tumours. With regards to vascular malformations, the direction of venous drainage and therefore the most pressing clinical questions concerning the need for therapeutic intervention can be ascertained. This technique is the only MR imaging method able to provide dynamic information on the cerebral vasculature. It therefore constitutes a helpful adjunct to the imaging armentarium in many clinical situations.     

Contrast-enhanced time-resolved 3-D MRA: applications in neurosurgery and interventional neuroradiology

Purpose

The decision-making process in the endovascular treatment of cranial dural AV fistulas and angiomas and their follow-up after treatment is usually based on conventional digital subtraction angiography (DSA). Likewise, acquiring the vascular and hemodynamic information needed for presurgical evaluation of meningiomas may necessitate DSA or different MR-based angiographic methods to assess the arterial displacement, the location of bridging veins and tumor feeders, and the degree of vascularization. New techniques of contrast-enhanced MR angiography (MRA) permit the acquisition of images with high temporal and spatial resolution. The purpose of this study was to evaluate the applicability and clinical use of a newly developed contrast-enhanced 3-D dynamic MRA protocol for neurointerventional and neurosurgical planning and decision making.

Methods

With a 3-T whole-body scanner (Philips Achieva), a 3-D dynamic contrast-enhanced (MultiHance, Bracco) MRA sequence with parallel imaging, and intelligent k-space readout (keyhole and “CENTRA” k-space filling) was added to structural MRI in patients with meningiomas, dural arteriovenous fistulas and pial arteriovenous malformations. The sequence had a temporal resolution of 1.3 s per 3-D volume with a spatial resolution of 0.566×0.566×1.5 mm per voxel in each 3-D volume and lasted 25.2 s. DSA was performed in selected patients following MRI.

Results

In patients with arteriovenous fistulas and malformations, MRA allowed the vascular shunt to be identified and correctly classified. Hemodynamic characteristics and venous architecture were clearly demonstrated. Larger feeding arteries could be identified in all patients. In meningiomas, MRA enabled assessment of the displacement of the cerebral arteries, depiction of the tumor feeding vessels, and evaluation of the anatomy of the venous system. The extent of tumor vascularization could be assessed in all patients and correlated with the histopathological findings that indicated hypervascularization.

Conclusion

High temporal and spatial resolution 3-D MRA may allow correct identification and classification of fistulas and angiomas and help to reduce the number of pre-or postinterventional invasive diagnostic angiograms. This sequence is also helpful for characterizing the degree of vascularization in preoperative evaluation of meningiomas and to select meningiomas suitable for embolization. Displacement of normal arteries and depiction of the venous anatomy can be achieved cost-effectively in a short period of time. The high spatial resolution also permits improved demonstration of the major feeding arteries, which helps to reduce the number of conventional angiograms required for meningioma evaluation.

     

Analysis of 30 Spinal Angiograms Falsely Reported as Normal in 18 Patients with Subsequently Documented Spinal Vascular Malformations

BACKGROUND AND PURPOSE:The early diagnosis of spinal vascular malformations suffers from the nonspecificity of their clinical and radiologic presentations. Spinal angiography requires a methodical approach to offer a high diagnostic yield. The prospect of false-negative studies is particularly distressing when addressing conditions with a narrow therapeutic window. The purpose of this study was to identify factors leading to missed findings or inadequate studies in patients with spinal vascular malformations.MATERIALS AND METHODS:The clinical records, laboratory findings, and imaging features of 18 patients with spinal arteriovenous fistulas and at least 1 prior angiogram read as normal were reviewed. The clinical status was evaluated before and after treatment by using the Aminoff-Logue Disability Scale.RESULTS:Eighteen patients with 19 lesions underwent a total of 30 negative spinal angiograms. The lesions included 9 epidural arteriovenous fistulas, 8 dural arteriovenous fistulas, and 2 perimedullary arteriovenous fistulas. Seventeen patients underwent endovascular (11) or surgical (6) treatment, with a delay ranging between 1 week and 32 months; the Aminoff-Logue score improved in 13 (76.5%). The following factors were identified as the causes of the inadequate results: 1) lesion angiographically documented but not identified (55.6%); 2) region of interest not documented (29.6%); or 3) level investigated but injection technically inadequate (14.8%).CONCLUSIONS:All the angiograms falsely reported as normal were caused by correctible, operator-dependent factors. The nonrecognition of documented lesions was the most common cause of error. The potential for false-negative studies should be reduced by the adoption of rigorous technical and training standards and by second opinion reviews.

Spinal vascular malformations can be subdivided into high-flow and low-flow lesions. The high-flow group includes spinal arteriovenous malformations and prominent perimedullary arteriovenous fistulas (PmAVF, Merland type 2 and 3¹). The low-flow group is principally made of spinal dural (SDAVF) and spinal epidural arteriovenous fistulas (SEAVF) as well as less common small PmAVFs (Merland type 1). Although the detection of fast-flow lesions is generally straightforward with noninvasive imaging because of the large size of the vessels involved, low-flow anomalies—which are more frequent—can represent a major diagnostic challenge. Low-flow arteriovenous fistulas typically occur in older men presenting with a venous hypertensive myelopathy secondary to the drainage of the fistula into the perimedullary venous system.^2–5 They are characterized by progressive courses and narrow therapeutic windows, yet their diagnoses are often established with considerable delay, if at all.⁵ This situation is in large part related to their nonspecific clinical presentations and the ambiguous noninvasive imaging characteristics of venous hypertensive myelopathy. Spinal DSA, the “gold standard” technique for the investigation of spinal vascular anomalies, remains necessary to identify and characterize these lesions. Modern spinal DSA is associated with extremely low risks of neurologic or systemic complications,⁶ but it is a technically demanding procedure that requires a methodical approach to offer a high diagnostic yield.This article analyzes the clinical and imaging characteristics of 18 patients with proved spinal vascular malformations but initial angiographic investigation reported as normal. The purpose of this review was to identify the factors that led to missed findings or inadequate studies and propose strategies aimed at reducing their impact.     

Intracranial dural arteriovenous fistulas: evaluation with combined 3D time-of-flight MR angiography and MR digital subtraction angiography

OBJECTIVE: The purpose of this study was to compare the diagnostic utility of 3D time-of-flight (TOF) MR angiography and MR digital subtraction angiography in patients with angiographically proven moderate- to high-flow intracranial dural arteriovenous fistula. MATERIALS AND METHODS: Two neuroradiologists, unaware of patients' histories and angiographic findings, retrospectively reviewed 17 MR angiograms with 3D TOF MR angiography and MR digital subtraction angiography in 15 patients with dural arteriovenous fistula and also reviewed 35 MR angiograms in control patients without findings of dural arteriovenous fistula on angiography. Disagreements were resolved by consensus. RESULTS: In patients with dural arteriovenous fistula, source images of 3D TOF MR angiography showed two abnormal findings: multiple high-intensity curvilinear or nodular structures adjacent to the sinus wall and high-intensity areas in the venous sinus. Findings of multiple high-intensity structures adjacent to the sinus wall were observed in all cases of dural arteriovenous fistula. Findings of high-intensity areas in the venous sinus were observed in 13 of 17 cases of dural arteriovenous fistula. Findings of multiple high-intensity structures adjacent to the sinus wall were not observed in any control subjects. Findings of high-intensity areas within the venous sinus were observed in five of 35 control subjects. Findings of MR digital subtraction angiography showed early filling of the venous sinus, suggestive of dural arteriovenous fistula, in 13 of 15 patients with dural arteriovenous fistula. Sensitivity and specificity of multiple high-intensity structures adjacent to the sinus wall, high-intensity areas in the venous sinus, and early filling of the venous sinus were 100% and 100%, 76% and 86%, and 87% and 100%, respectively. Although 3D TOF MR angiography failed to show the findings of retrograde cortical venous drainage and venous sinus occlusion, MR digital subtraction angiography clearly showed both findings in all five subjects. CONCLUSION: A protocol including both 3D TOF MR angiography (source images) and MR digital subtraction angiography allowed the diagnosis of moderate- to high-flow dural arteriovenous fistula. In addition, cortical venous drainage was reliably noted in a small subset of patients.     

Vasos intracraneales en localización anómala en adultos

Anomalous intracranial vessels are not uncommon, and this finding is not always associated with arteriovenous malformations. Other conditions such as anomalous connections between arteries or phlebitc patterns can also present as vessels with abnormal intracranial locations. Noninvasive diagnosis is important to determine whether to do more invasive tests such as cerebral digital subtraction angiography or to estimate the risk of bleeding in arteriovenous malformations and therefore to evaluate the need for endovascular/surgical treatment. In this paper, we present an algorithm for the differential diagnosis of anomalous intracranial vessels according to their location (intra/extra-axial) and function (whether the vessels are arterialized). Moreover, we analyze the important points of the angioarchitecture of the principal arteriovenous malformations with risk of intracranial bleeding, such as pial arteriovenous malformations and dural fistulas.