脊髓血管畸形的影像学诊断和血管内栓塞治疗

复杂的脊髓血管解剖，包括脊髓多来源的供养动脉和多去路的引流静脉，导致脊髓血管畸形的影像学诊断变得困难。脊髓血管畸形大致分为三类：髓内动静脉畸形、髓周动静脉瘘和硬脊膜动静脉瘘。髓内动静脉畸形的畸形团位于或大部分位于脊髓实质内。其供血动脉为脊髓前动脉及其分支，脊髓后动脉也经常同时参与供血。其引流静脉常同时向脊髓前、后静脉引流。最典型的临床症状为畸形团破裂出血。其治疗以分次血管内栓塞治疗为主。手术切除弊大于利，一般不采用。治疗的目的是改善症状而非解剖治愈。髓周动静脉瘘是脊髓外的软膜动脉与静脉的直接交通，常常是脊髓前动脉或脊髓后动脉与相应的静脉直接沟通。主要临床症状亦多为出血，亦可源于脊髓缺血或水肿。治疗方法和原则类似髓内动静脉畸形，但流速缓慢的位于圆锥和终丝部位的髓周动静脉瘘多手术切除。硬脊膜动静脉瘘几乎占所有脊髓血管畸形的80%。男女比例7:1,40岁以上多发。其瘘口位于硬脊膜内和硬脊膜内、外层之间，常靠近椎间孔的神经根，是根动脉的硬脊硬支与根髓静脉之间的直接交通。主要临床症状源于脊髓静脉高压引起的脊髓水肿和坏死。应用稀胶栓塞治疗成功率可达90%。胶一定要在瘘口和引流静脉起始端形成良好的铸型方能避免复发。手术夹闭瘘口简单，效果好，但创伤较大。

Spinal Cord Vascular Malformations:Imaging and Endovascular Treatment

The complexity of the spinal cord vascular, including its feeding artery's multi-source and multi - drainage veins, leads to the diagnosis difficult of spinal cord vascular malformations. The spinal cord vascular malformations were classified into intramedullary arteriovenous malformation(AVM), perimedullary arteriovenous fistular(PMAVF) and spinal dural arteriovenous fistulae(SDAVF) .The nidus of the intramedullary AVM was buried or partly buried in the cord parenchyma. The feeders include anterior spinal artery and its branches, and simultaneously it is frequently fed by posterior spinal artery.It usually drainaged to anterior and posterior spinal vein at the same time.The most striking clinical symptom of this type is hemorrhage. The main therapy modality is not surgery resection but staged endovascular embolization. The therapy target is clinical symptoms improvement, not the anatomy cure. The PMAVF is the shunt between a pial artery and vein,presenting outside the spinal cord.Usually the anterior or posterior spinal artery directly communicates to the coresponding spinal veins. The clinical presentation is most frequently characterized by acute onset of hemorrhage, but it may be insidious myelopathy. The therapy modality was as same as the intramedullary AVM with only exception of slow -flow PMAVFs located at the conus or filum terminale, which needs surgery resection. 80% spinal vascular malformations were SDAVF, which is located within the dura mater between the outer and inner dural layers, usually close to the nerve root at the intervertebral foramen. Male/ Female is 7/ 1. Most patients are older than 40 years old. The lesions are direct AVFs that link the dural branch of radicular artery with radiculomedullary vein. The retrograde flow of shunted blood results in venous congestion in the spinalcord, eventually to provoke progressive myelopathy. Successful embolization with diluted NBCA may be achieved in 90% . NBCA must safely reach the proximal draining vein in order to prevent the fistular re-canalization. Surgery clips of the fistular and the proximal draining vein was simple, safe and effective, but the trauma is comparatively obvious.