颈动脉海绵窦瘘的血管内栓塞治疗

目的　探讨不同的栓塞材料在颈动脉海绵窦瘘 (CCF)的血管内栓塞治疗中的应用。方法　回顾分析了 2 3例CCF血管内栓塞治疗病例。其中 2 2例外伤性CCF ,19例使用了可脱性球囊 ,3例使用了金属微弹簧圈作栓塞材料 ;1例自发性CCF ,使用了NB CA胶作栓塞剂。结果　可脱性球囊栓塞 19例 ,均获得临床治愈 ,其中 12例保持了患侧颈内动脉的通畅 ,获得解剖治愈 ;金属微弹簧圈栓塞 3例 ,2例成功 ,1例因弹簧圈异位栓塞于右大脑中动脉的分支 ,导致病人失语和半身不遂 ,1例自发性CCF ,经患侧脑膜副动脉注射NBCA胶 ,部分NBCA进入海绵窦内 ,病人获得临床治愈。结论　CCF首选血管内栓塞治疗 ,而可脱性球囊是一种理想的栓塞材料。由于金属微弹簧圈可控性差 ,不够安全 ,不应再被作为经颈内动脉途径的栓塞材料。     

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.     

Transarterial platinum coil embolization of carotid-cavernous fistulas

Of the 227 embolization procedures performed by our neurointerventional section for symptomatic carotid-cavernous fistulas over the past 10 years, five involved placement of platinum coils in the cavernous sinus from a transarterial route. In four patients, prior transarterial balloon procedures had failed to produce fistula closure. In the fifth patient, with Ehlers-Danlos syndrome, a prior transvenous embolization attempt was unsuccessful. In three patients, complete closure of the carotid-cavernous fistula was achieved with preservation of the parent artery. In one patient, the earliest treated, a portion of a platinum coil projected through the fistula into the parent artery. To eliminate the risk of clot formation and distal embolization, internal carotid occlusion was performed and tolerated without deficits. In the last patient, closure of the anterior drainage was achieved, but complicated by distal migration of the platinum coils with transient aggravation of ocular symptoms. Attempts to occlude the remaining cortical drainage were unsuccessful with platinum coils; therefore, a balloon was used to obliterate the small remaining fistula. Transarterial platinum coil embolization is an alternative treatment for symptomatic carotid-cavernous fistulas that cannot be closed successfully by other embolization techniques. The development of shorter, more thrombogenic, detachable or retrievable coils may make this technique more promising in the future.     

Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients

BACKGROUND AND PURPOSE: Carotid cavernous fistulas (CCF) can be effectively treated by using different therapeutic alternatives such as detachable balloons and detachable coils, alone or in combination with N-butyl-2-cyanoacrylate (n-BCA) or Onyx. Stents have also been used in an attempt to improve preservation of the parent artery while still occluding the fistula. We present our experience using balloon-expandable covered stents to treat CCF, focusing on arterial wall reconstruction. To our knowledge, this is the first series with midterm follow-up between 3 months and 3.5 years. MATERIALS AND METHODS: From the 46 CCF treated at our institution between November 1998 and September 2006, a total of 7 posttraumatic direct CCF were treated using polytetrafluoroethylene (PTFE)-covered stents between April 2003 and September 2006. Five were treated with covered stents alone. One patient with transection of the internal carotid artery (ICA) first underwent bare stent placement to provide support for the covered stent. One patient had to be treated with coils and n-BCA. RESULTS: Control angiograms obtained in the 7 patients demonstrated occlusion of the fistula and preservation of the ICA in all cases. There was no mortality and no immediate postprocedural morbidity. There was 1 case of morbidity identified at 1-month follow-up with asymptomatic occlusion of the ICA; the other 6 patients had angiographic follow-up between 3 and 42 months (mean, 18.4 months), with persistent occlusion of the fistulas, patent stent grafts, and no significant intimal hyperplasia. CONCLUSIONS: PTFE-covered stents are evolving as a promising intracranial therapeutic alternative to treat CCF and preserve the parent artery by reconstructing the arterial wall. They should be considered in patients in whom fistulas cannot be successfully occluded with detachable balloons or detachable coils. More investigation is required to further develop their specifications and indications.     

Transvenous embolization of direct carotid cavernous fistulas

Of 165 cases of direct carotid cavernous fistula, 14 (8.5%) were treated from a transvenous approach. Twelve of these were treated through the inferior petrosal sinus and one through the superior ophthalmic vein. In one patient, both approaches were used. The embolic agents were as follows: five patients had balloons only, four patients had minicoils alone, three patients had coils and liquid adhesives, one had balloons and coils, and one had balloons and liquid adhesives. Among the patients who were treated from a transvenous approach, three had an occluded carotid artery caused by trauma, nine failed transarterial balloon attempts, and one had a prior trapping procedure. In the remaining patient, who had Ehlers-Danlos syndrome, a transarterial approach was judged to be too dangerous. This patient suffered a fatal pontine hemorrhage after subtotal transvenous occlusion of the carotid cavernous fistula with diversion of flow into cortical veins. Another complication occurred when the inferior petrosal sinus was perforated during catheterization, causing a small subarachnoid hemorrhage. The tear was immediately closed with minicoils, and surgical exposure and embolization resulted in complete cure. Of the remaining 12 patients treated, 11 were completely cured and one showed angiographic and clinical improvement. Transarterial balloon embolization remains the procedure of choice in the treatment of symptomatic carotid cavernous fistulas; however, transvenous embolization is an alternative when the arterial route fails.     

可脱球囊栓塞术在海绵窦瘘治疗中的应用 (附 2 7例报告 )

目的　研究微导管可脱球囊技术治疗海绵窦瘘的临床意义。方法 :2 6例外伤性颈内动脉海绵窦瘘 (TCCF)患者和 1例大脑前动脉 (A1段 )动脉瘤破裂合并海绵窦瘘患者采用微导管可脱球囊技术进行栓塞治疗 ,以经颅多普勒 (TCD)进行复查 ,所有患者均随访 6月以上。结果 :2 2例CCF患者均成功栓塞瘘口并保持颈内动脉通畅 ,其中 2 0例为一次栓塞成功 ,2例因球囊过早泄漏而行 2次栓塞治疗。对 1例A1段动脉瘤破裂合并海绵窦瘘患者成功施行了双球囊动脉瘤颈孤立术。 4例行颈内动脉闭塞术。本组病例未发生严重并发症。结论 :微导管可脱球囊技术是对海绵窦瘘的一种微创、安全、有效的治疗方法。     

Transvenous n-butyl-cyanoacrylate infusion for complex dural carotid cavernous fistulas: technical considerations and clinical outcome

BACKGROUND AND PURPOSE: Endovascular transvenous embolization has been advocated as the treatment technique for dural carotid cavernous fistulas (dCCFs). Most centers use platinum coils primarily. The purpose of this study was to evaluate the technical aspects, efficacy, and safety of transvenous n-butyl cyanoacrylate (n-BCA) infusion in dCCFs as a primary alternative or adjunct to coil embolization. METHODS: We retrospectively evaluated 14 patients with dCCFs who were treated at this institution from 1999 to 2004 by using n-BCA infusion alone or in combination with coils. The efficacy of treatment and safety aspects were studied in dCCFs of Barrow type B (4/14), C (2/14), and D (8/14). Six patients were treated with transvenous n-BCA infusion alone in the cavernous sinus, 7 with a combination of transvenous n-BCA and coil embolization, and one with transvenous n-BCA combined with transarterial polyvinyl alcohol (PVA)-particle embolization of the feeding arteries. RESULTS: An angiographic obliteration and clinical cure was achieved in all patients. Technical complications were nonsymptomatic and included spillage of an n-BCA droplet into a middle cerebral artery branch retrograde through the arteriovenous fistulas in one patient and perforation of the inferior petrosal sinus during microcatheter placement in another. A third patient developed temporary palsy of the sixth cranial nerve a few days after the treatment. CONCLUSION: In this small series, the use of n-BCA either alone or in conjunction with detachable coils was a safe and effective technique for the treatment of symptomatic patients presenting with complex dCCFs.     

外伤性颈内动脉海绵窦瘘并严重鼻衄的血管内介入治疗

目的 探讨血管内介入治疗外伤性颈内动脉海绵窦瘘(TCCF)合并严重鼻衄的策略和疗效.方法 26例TCCF并严重鼻衄的患者进行了血管内介入治疗,其中24例采用了可脱性球囊栓塞瘘口或闭塞颈内动脉;1例采用解脱式微弹簧圈栓塞;1例采用覆膜支架进行治疗.结果 26例中,9例1次性栓塞了瘘口,假性动脉瘤消失,颈内动脉通畅;15例1次性栓塞了瘘口和闭塞颈内动脉;解脱式微弹簧圈栓塞海绵窦,瘘口基本消失,颈内动脉通畅1例;覆膜支架闭塞瘘口,颈内动脉保持通畅1例.术后26例均未再发生鼻衄.结论 TCCF并严重鼻衄应尽早进行DSA确诊,尽早或急症进行治疗.血管内介入治疗TCCF合并严重鼻衄是一种首选、安全和有效的治疗方法.     

Selective occlusion of a carotid-cavernous sinus fistula following transphenoidal hypophysectomy using a detachable balloon catheter

A case of a carotid cavernous sinus fistula following transphenoidal hypophysectomy is reported. A selective occlusion of the fistula with patency of the carotid artery was achieved by means of a detachable balloon catheter.     

双导管球囊技术治疗高流量颈动脉海绵窦瘘

目的探讨双球囊导管技术治疗高流量颈动脉海绵窦瘘(CCF)的可行性及疗效。方法随机选择1枚可脱性球囊无法闭塞的CCF患者3例,双侧股动脉置管,送2枚球囊进入瘘口,调整位置,充盈2枚球囊,使瘘口完全闭塞后再解脱球囊,观察栓塞效果和颈内动脉通畅情况,评价该技术的可行性。结果3例患者均1次性完全闭塞瘘口,颈内动脉皆通畅,操作过程简单易行,未增加介入治疗的危险性。结论双导管球囊技术能在保证颈内动脉通畅的前提下简单有效地治疗1枚球囊无法闭塞的CCF。     

Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus

BACKGROUND AND PURPOSE:Combined transarterial balloon-assisted endovascular embolization with double-lumen balloon microcatheters and concomitant transvenous balloon protection was described as a promising treatment technique for dural arteriovenous fistulae of the transverse and sigmoid sinus. The purpose of this study was to evaluate the technical efficacy and safety of this combined treatment technique.MATERIALS AND METHODS:Nine consecutive patients presenting with dural arteriovenous fistulas of the transverse and sigmoid sinuses underwent combined transarterial and transvenous balloon-assisted endovascular embolization. Prospectively collected data were reviewed to assess the technical success rate, complication rate, and clinical outcome.RESULTS:Six patients presented with clinically symptomatic Borden type I, and 3 patients, with Borden type II dural arteriovenous fistulas of the transverse and sigmoid sinuses (3 men, 6 women; mean age, 50.4 years). Transarterial embolization was performed with a double-lumen balloon with Onyx and concomitant transvenous sinus protection with a dedicated venous remodeling balloon. Complete angiographic occlusion at the latest follow-up (mean, 4.8 months) was achieved in 6 patients, and near-complete occlusion, in 2 patients. Clinical cure or remission of symptoms was obtained in 6 and 2 patients, respectively. One patient with a residual fistula underwent further treatment in which the dural arteriovenous fistula was cured by sinus occlusion. Complete occlusion of the dural arteriovenous fistula was visible on the follow-up angiography after final treatment in 8 patients. One patient refused follow-up angiography but was free of symptoms. There were no immediate or delayed postinterventional complications.CONCLUSIONS:Transarterial balloon-assisted embolization of dural arteriovenous fistulas of the transverse and sigmoid sinuses with combined transvenous balloon protection is safe and offers a high rate of complete dural arteriovenous fistula occlusion and remission of clinical symptoms.

During the past few decades, endovascular embolization has become the first-line treatment for a wide range of dural arteriovenous fistulas (dAVFs). Several transarterial and transvenous endovascular approaches have been advocated. Preliminary studies on the use of double-lumen balloon microcatheters for transarterial embolization of dAVFs with Onyx (Covidien, Irvine, California) have shown encouraging results. These studies have reported high occlusion rates, reduction of reflux into the feeding artery, a reduced quantity of injected Onyx and peri-interventional time, and low complication rates.^1–9 In addition, transvenous balloon-assisted sinus protection during transarterial embolization has been reported to be another useful adjunct to the endovascular treatment of dAVFs.^10–12 Transvenous balloon protection of the recipient sinus has mainly been associated with a reduction in inadvertent occlusion of the lumen of a functioning sinus, preservation of venous patency, facilitation of occlusion of abnormal arteriovenous connections within the sinus wall and separate venous channels, and increased penetration of embolic material by retrograde reflux into other dural feeders of the fistula network. Techniques aiming to preserve the underlying sinus may have lower complication rates than sinus-occluding embolization techniques, in which the recipient venous sinus has to be sacrificed.¹³ Therefore, transarterial balloon-assisted embolization with a concomitant transvenous balloon protection technique theoretically has the advantages of both techniques combined; this combination leads to increased occlusion and reduced complication rates.The purpose of this study was to report the angiographic and clinical outcomes of patients with dAVFs of the transverse and sigmoid sinuses treated with a combined approach of transarterial balloon-assisted endovascular embolization and double-lumen balloon microcatheters with concomitant transvenous balloon protection.     

直接型颈动脉海绵窦瘘的血管内治疗

探讨血管内治疗对直接型颈动脉海绵窦瘘的价值。材料和方法：38例患者在治疗前均行脑血管造影检查，所有病例均采用经动脉途径，用可脱球囊导管进行栓塞治疗。结果：38例患者中有36例栓塞成功，其中34例患者瘘口完全闭塞。36例患者中有32例于栓塞后保留颈内动脉，4例行颈内动脉球囊闭塞术。术后36例患者的海绵窦综合症均有不同程度的好转。3例患者曾行经静脉途径可脱球囊栓塞治疗，但由于海绵窦内分隔的阻挡作用，球囊不能进入海绵窦及其瘘口附近而告失败。2例患者由于球囊早脱并移位于大脑中动脉分支血管内，导致患者发生失语和一侧肢体偏瘫。结论：血管内可脱球囊栓塞治疗直接型颈脉海绵窦瘘，其瘘口闭塞率高，死亡率低，是直接型颈动脉海绵窦瘘的首选治疗手段。     

经眼上静脉介入治疗海绵窦区硬脑膜动静脉瘘

目的 探讨眶上内侧缘切开穿刺眼上静脉介入栓塞海绵窦区硬脑膜动静脉瘘(AVF)的方法和疗效.方法 眶上内侧缘切开穿刺眼上静脉使用微弹簧圈介入栓塞海绵窦区硬脑膜AVF 16例.结果 所有患者均临床治愈,1例虽将海绵窦致密填塞,但仍有少量翼丛引流,压颈1个月后消失.栓塞术后并发症主要表现为头痛和呕吐.2例术后出现轻度复视,后自行恢复,无一例出现永久性介入相关并发症.临床随访5个月到6年,患者均无临床症状复发.结论 眶上内侧缘切开穿刺眼上静脉入路介入栓塞是海绵窦区硬脑膜动静瘘治疗安全有效的方法 之一.     

Angiographic follow-up of traumatic carotid cavernous fistulas treated with endovascular stent graft placement

BACKGROUND AND PURPOSE: Endovascular treatment (EVT) of carotid cavernous fistulas (CCFs) is based on various techniques, mainly those using detachable balloons. Coronary covered stent grafts have been sporadically used in the intracranial arteries and only 2 traumatic CCFs have been reported in the literature; moreover, there is poor information about the long-term follow-up. We present 8 cases of CCFs treated by the placement of a covered stent, 5 of which have a 1-year clinical and angiographic follow-up. METHODS: Eight patients with posttraumatic CCF were treated by positioning a covered stent in the intracranial internal carotid artery (ICA) to occlude the fistula. They received periodic clinical and angiographic follow-up to evaluate the patency and the stability of clinical results. RESULTS: In all cases, the symptoms related to the CCF regressed after treatment and did not recur in the follow-up. Two patients presented residual filling of the CCF at the end of the procedure. The angiographic follow-up revealed in 6 patients of 7 a good patency of the ICA; in 1 patient, there was an ICA asymptomatic occlusion. One patient required transvenous coil occlusion of the cavernous sinus. CONCLUSION: When standard treatments fail, covered stent grafts can be used as a valid alternative in the treatment of CCFs, but more data are needed, especially in the long-term follow-up.     

Failure to demonstrate a direct caroticocavernous fistula due to arterialisation of the ipsilateral cavernous sinus

We report a woman in whom a small direct caroticocavernous fistula (DCCF) was revealed after successful transarterial occlusion of a contralateral fistula which drained into both cavernous sinuses. We underline that a second smaller fistula can be masked by a contralateral larger one due to the lack of pressure gradient between the internal carotid artery (ICA) and arterialised blood in the ipsilateral cavernous sinus. We suggest that bilateral ICA angiograms should be performed before and after occlusion of all DCCF. Received: 21 January 1998 Accepted: 12 May 1998     

可脱球囊治疗外伤性颈内动脉海绵窦瘘

目的：研究外伤性颈内动脉海绵窦瘘的栓塞治疗。材料与方法：本文对5例外伤性颈内动脉海绵窦瘘患者施行了血管内介入栓塞术。所有患者均于手术前行Matas试验。结果：4例患者经可脱球囊栓塞术治疗，颈内动脉海绵瘘消失，颈内动脉保持通畅，颈内动脉海绵窦瘘的临床综合征于治疗后消失。1例由于瘘口较大，球囊不能完整闭塞瘘口，因该患者健侧颈内动脉代偿供应患侧的能力差，故无法栓塞患侧颈内动脉，栓塞术后该患者临床症状及体征有所改善但未能完全消除。结论：栓塞治疗对于外伤性预内动脉海绵窦瘘是一种有效治疗方法。     

Persistent primitive trigeminal artery associated with aneurysm: report of two cases and review of the literature

We present two cases of persistent primitive trigeminal artery (PPTA) associated with a giant aneurysm originating at the opening of the PPTA on the internal carotid artery (ICA). In one case, opening of the PPTA occurred 4 months after balloon occlusion of the ICA, when a giant aneurysm located at the cavernous segment of the ICA was being treated. The PPTA was occluded successfully using a Guglielmi detachable coil (GDC). A vertebral artery approach was taken. This is the first report of the opening of a PPTA associated with contrast filling of the aneurysm after balloon occlusion of the parent artery. The possibility of contrast filling of the aneurysm via potential PPTA should therefore be considered in the event of an ICA aneurysm with parent artery occlusion.     

经动脉途径低浓度氰基丙烯酸正丁酯栓塞治疗海绵窦硬脑膜动静脉瘘

目的 探讨经动脉途径低浓度(14%～25%)氰基丙烯酸正丁酯(NBCA)栓塞治疗海绵窦硬脑膜动静脉瘘(DCCFs)的可行性.方法 8例DCCFs患者均经动脉入路,使用微导管嵌顿技术注入低浓度NBCA行栓塞治疗.其中5例为经静脉入路栓塞失败者,3例为不可行静脉入路栓塞治疗者.结果 5例患者术后即刻血管造影DCCFs完全消失;随访6～12个月,临床症状完全消失,血管造影未发现DCCFs复发.3例患者术后即刻血管造影DCCFs残留,但血液分流量减少;随访3个月,血管造影血液分流明显减少、临床症状改善2例,血液分流和临床症状均消失1例.1例患者术后出现一过性眼部症状恶化、第Ⅵ脑神经麻痹,经治疗后3 d症状消失.结论 经动脉采用微导管嵌顿技术低浓度NBCA栓塞DCCFs是一种安全有效的方法,对于经静脉入路栓塞失败或不能经静脉入路治疗的患者,可能是一种较为理想的选择.     

Occlusion of arteriovenous malformations of the cavernous sinus via the superior ophthalmic vein

The treatment of five patients with dural arteriovenous malformations (AVMs) of the cavernous sinus via the superior ophthalmic vein (SOV) is reported. The procedure was performed by transcutaneous puncture of the SOV under the guidance of real-time digital subtraction angiography. Complete resolution of the ocular symptoms was achieved in all cases. Angiograms after embolization showed complete obliteration of the malformation in four cases and partial obliteration in one. This method can cure dural AVMs of the cavernous sinus, with preservation of blood flow in the internal carotid artery. It is particularly indicated when the SOV is enlarged and when (1) dural AVMs of the cavernous sinus are fed by small branches of the internal carotid artery or direct carotid cavernous fistulas with small tears; (2) dural AVMs of the cavernous sinus are fed by multiple branches from both the internal and external carotid arteries, one or both sides; or (3) dural AVMs of the cavernous sinus or direct carotid cavernous fistulas recur after trapping of the internal carotid artery. Transcutaneous puncture and catheterization of the SOV was performed safely with the aid of digital subtraction angiography. The SOV approach was able to treat the fistula with preservation of the internal carotid artery.     

创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊断和治疗

目的 探讨创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊疗方法.方法 介入方法诊断和治疗6例创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤患者.结果 5例出现反复鼻腔大出血;所有患者均行瘘口和假性动脉瘤球囊闭塞,2例颈内动脉保留,1例合并对侧间接型颈动脉海绵窦瘘行经面静脉-眼上静脉瘘口弹簧圈栓塞术.术后颅内杂音均即刻消失,结膜充血水肿2周～3个月内消退.无介入相关并发症.所有患者均行随访,无临床症状复发,均恢复工作.结论 车祸是致颈动脉海绵窦瘘合并蝶窦假性动脉瘤的主要原因;受力部位多集中在患侧眶额部到眶颧部的眶前外侧区;头颅MRI结合临床表现对于术前确诊该病非常有帮助;可脱球囊闭塞瘘口和假性动脉瘤或闭塞颈内动脉是安全、有效的治疗方法.