外伤性颈动脉海绵窦瘘（TCCF）的血管内治疗

目的：总结外伤性颈动脉海绵窦瘘（TCCF）治疗方法的选择、栓塞技术及疗效。方法：TCCF检塞治疗26例患者，经动脉入路25例，经静脉入路1例；用可脱性球囊检塞瘘口21例，行颈内动脉球囊闭塞术3例，用微弹簧圈检塞治疗2例。结果；24例患者一次性检塞成功，2例检塞后因球囊早泄复发，再次经球囊检塞后治愈。一次性检塞治愈率92.3%，颈内动脉畅通率88.5%(23/26)。随访2-12个月，有2例并发假性动脉瘤形成，1例症状明显行GDC检塞治疗后治愈，另1例无症状继续随访，本组无死亡及其他并发症。结论：经动脉入路用可脱性球囊检塞瘘口是治疗TCCF的首选方法：对于球囊无法进入的小瘘口TCCF可选 用微弹簧圈检塞；若动脉入路不能或失败可行静脉入路检塞瘘口；对于瘘口在放置多个球囊仍不能将瘘口检塞的患者，可考虑闭塞颈内动脉。     

经眼上静脉栓塞治疗外伤性颈内动脉海绵窦瘘

随着介入材料与技术的进步，血管内介入治疗已成为外伤性颈内动脉海绵窦瘘（TCCF）的首选方法。多采用经股动脉途径直接栓塞瘘口并力求保持颈内动脉通畅。但由于瘘口的大小及其与颈内动脉的角度不同等原因，部分病例并不能成功，而导致同侧颈内动脉闭塞。为保证颈内动脉通畅，可采用静脉途径栓塞海绵窦及瘘口，现就笔者采用眼上静脉途径治疗TCCF的体会报道如下。     

血管内治疗外伤性颈内动脉损伤

目的探讨血管内治疗对外伤性颈内动脉损伤的临床价值。方法16例外伤性颈内动脉损伤患者,经DSA造影证实为假性动脉瘤3例、岩部巨大蛇性动脉瘤及颈内动脉起始部动脉瘤各1例以及颈内动脉海绵窦瘘11例,分别采用可脱落球囊、电解可脱式弹簧圈（GDC）或带膜内支架对损伤部位进行动脉内栓塞治疗。结果对3例假性动脉瘤及1例岩部巨大蛇性动脉瘤患者以可脱落球囊闭塞患侧颈内动脉成功。9例颈内动脉海绵窦瘘（CCF）在保持颈内动脉通畅的情况下采用球囊成功栓塞瘘口,1例CCF予以GDC填塞海绵窦;其余1例CCF两次球囊栓塞均失败,但术后24h患侧凸眼明显回缩,间断按压患侧颈内动脉1周后患者临床症状和体征消失。1例颈内动脉起始部动脉瘤行带膜内支架成功植入,动脉瘤被旷置,颈内动脉保持通畅。结论血管内治疗是外伤性颈内动脉损伤安全有效的治疗方法。     

外伤性颈内动脉海绵窦瘘的诊断与介入栓塞治疗（附4例报告）

[摘要]目的探讨外伤性颈内动脉海绵窦瘘的诊断和血管内治疗。方法对有头部外伤病史及典型临床表现的患者积极行数字减影血管造影（digitalsubtractionangiography,DSA）检查,有4例确诊后经股动脉入路,用可脱性球囊进行栓塞治疗。3例保持了患侧颈内动脉的通畅,1例行瘘口远近端的颈内动脉闭塞术;3例患者应用1个球囊,1例应用2个球囊。结果4例患者瘘I：1完全闭塞,临床症状缓解,1例于首次术后12h症状再发,再次行栓塞治疗后缓解痊愈。结论DSA检查是诊断颈内动脉海绵窦瘘的金标准;可脱性球囊栓塞治疗是颈内动脉海绵窦瘘的首选治疗方法。     

外伤性颈内动脉假性动脉瘤的血管内栓塞治疗

报告４例外伤性颈内动脉海绵窦段假性动脉瘤经血管内栓塞治愈头面部外伤，颅风底骨折和迟发性周期性鼻衄是论断外伤性颈内动脉假性动脉瘤的主要依据，可脱球囊内充ＨＥＭＡ栓塞动脉瘤及颈内动脉２例，钨线螺旋圈栓塞脉瘤１例，螺旋圈和可脱球囊联合栓塞动脉瘤１例，后２例颈内动脉通畅，血管内栓塞治疗是外伤性颈内动脉性动脉瘤的最佳治疗方法。     

颅内动脉瘤和颈内动脉海绵窦瘘的微弹簧圈栓塞治疗

采用介入放射学方法对6例颅内动脉瘤和14例颈内动脉海绵窦瘘进行了国产微弹簧圈的栓塞治疗。结果4例脑动脉瘤瘤腔栓塞90％,另2例瘤腔完全充填闭塞。14例CCF有12例栓塞满意,栓塞后一周杂音逐渐消失。2例行2次栓塞。本组结果提示微弹簧圈栓塞是颅内动脉瘤和颈内动脉海绵窦瘘的一个简单有效的方法,对其适应证和并发症的预防应当进一步探讨。     

经动脉栓塞治疗颈内动脉海绵窦瘘的疗效

目的分析颈内动脉海绵窦瘘患者经动脉栓塞治疗的疗效。方法回顾性分析我院经动脉栓塞治疗的52例颈内动脉海绵窦瘘患者资料,分析其治疗的成功率、复发率及并发症,并随访其短期及长期疗效。结果 52例患者中,48例(48/52,92.31%)栓塞成功,4例栓塞失败后行外科手术治疗。48例栓塞成功患者中,41例(41/48,85.42%)成功闭塞瘘口且保持颈内动脉通畅。4例(4/52,7.69%)术后复发,分别经压颈、球囊、液态胶栓塞及闭塞颈动脉的方法治疗成功。44例无复发患者短期内所有患者眼部症状缓解,长期随访中无复发病例。结论经动脉栓塞治疗颈内动脉海绵窦瘘成功率高、复发率低,并发症少。可脱球囊栓塞为其首选方法,辅以弹簧圈、液态胶栓塞,其短期及长期疗效均可肯定。     

颈内动脉海绵窦瘘的血管内治疗（附78例报告）

目的介绍治疗颈内动脉海绵窦瘘的经验和体会。方法采用Seldinger法插入导管鞘后，用带Bait可脱球囊的magic—BD导管透视下经导引管送达瘘口水平，当球囊突然“低头”或改变方向时，表示球囊已通过瘘口，进人海绵窦。以等渗造影剂交换气体后充盈球囊至杂音消失，造影证实瘘闭塞完全，并保持颈动脉通畅。结果本组78例共进行82次栓塞治疗，66例保持了患侧颈内动脉的通畅，12例闭塞了患侧颈内动脉，其中4例因球囊破裂，症状复发，又进行了二次栓塞治疗后治愈，无术后死亡和症状加重病例，但其中6例自发性患者症状消失4例，症状减轻2例；其余病例均在术后3天－3周内症状消失，经过1个月～5年的随访未见复发。结论血管内栓塞治疗已成为治疗颈内动脉海绵窦瘘的首选方法。     

外伤性颈动脉海绵窦瘘的血管内栓塞治疗

目的 比较不同方法治疗外伤性颈动脉海绵窦瘘的临床效果。方法 治疗中应用球囊导管,复杂的5例使用了胶及弹簧圈等栓塞材料。结果 10例成功闭塞瘘口且保留载瘤动脉通畅,2例闭塞载瘤动脉．结论 外伤性颈动脉海绵窦瘘应首选血管内栓塞治疗。有时瘘口太小,弹簧圈也是有效方法。     

颈内动脉闭塞术的初步临床应用

目的探讨颈内动脉闭塞术治疗颈内动脉血管性病变的价值。方法共5例患者,1例鼻咽癌行放疗后清创术,并发难以制止的鼻咽部大出血,双侧后鼻孔填塞无效;1例巨大颈内动脉眼段动脉瘤,无法手术夹闭;3例外伤后颈内动脉海绵窦瘘,单纯闭塞瘘口失败。采用Seldinger技术经股动脉穿刺置管行全脑血管造影,经球囊闭塞试验或病变侧压颈试验,病人耐受良好后方行闭塞术。闭塞材料为3例应用可脱弹簧圈,2例应用可脱球囊,闭塞位置为病变近端及瘘口。结果所有病例闭塞颈内动脉后,即行对侧颈动脉造影复查,可见前交通动脉和/或后交通动脉代偿良好,患者无明显并发症发生,病变未见显影。临床症状消失、无合并症发生,病变未见复发。结论颈内动脉闭塞术作为一种治疗颈动脉血管性疾病的方法,可以在不危及病人生命、加重病人病情的情况下,取得良好的治疗效果。     

Multimodal endovascular treatment for traumatic carotid- cavernous fistula

bjective：To present our experience in treating traumatic carotid-cavernous fistula （TCCF） by multimodal endovascular treatment.Methods：The management of 28 patients with TCCF between January 2004 and October 2012 in our hospital was retrospectively analyzed.According to imaging charateristics,24 cases were categorized into Type Ⅰ,3 Type Ⅱ and 1 Type Ⅲ.Totally 30 endovascular treatments were performed：Type Ⅰ TCCFs were obliterated via transvenous approach （7/25）,or transarterial approach （18/25） including 6 by detachable balloon occlusion,6 by microcoil embolization,3 by Hyperglide balloon-assisted coil embolization and 3 by a combination of detachable balloon and coil embolization.Two patients were treated with closure of internal carotid artery （ICA）.Type Ⅱ TCCFs were treated with transvenous embolotherapy （2/3） or carotid artery compression therapy （1/3）.The Type Ⅲ patient underwent detachable balloon embolization.Results：Immediate postoperative angiography showed recovery in 26 cases.One recurrent TCCF was found 2 weeks after detachable balloon embolization,and then reobliterated by transarterial coils.Reexamination found balloon deflation and fistula recanalization in 1 patient one month after combination of detachable balloons and coil embolization,which was cured by a second treatment via transvenous approach.The immediate angiography revealed residual blood flow in 4 patients.Among them,2 patients with delayed symptoms at follow-up needed a second treatment,1 patient recovered after carotid artery compression therapy,and the remaining patient＇s symptoms disappeared on digital subtraction angiography at five-month follow-up.CT angiography revealed anterior communicating artery aneurysm in the patient who was treated with closure ofICA 4 years later.Conclusion：According to results of images,characteristics of the fistula and type of drainage,proper treatment approach and embolic material can maximally heal pathological changes,retain the ipsilateral ICA patency and reduce long-term complications.     

Pitfalls of endovascular treatment for cerebral aneurysms]

Seventeen cases of unclippable aneurysms were treated by the endovascular balloon technique. Nine of them involved the anterior circulation, and eight involved the posterior circulation. Eleven of them were treated by parent artery occlusion with detachable balloons. Three were treated by endosaccular balloon embolization, and three cases combined with AVMs were occluded using ethylene vinyl alcohol copolymer (EVAL) including feeding arteries of the AVMs. Embolic complications occurred in one case of an IC bifurcation giant aneurysm treated by parent artery occlusion. Ischemic complications also appeared in two cases of aneurysms treated by endosaccular balloon embolization. In one case, the thrombus in the aneurysm propagated into the parent artery and occluded it later. In another case, the displaced balloon had obliterated the parent artery 6 hours after the embolization. Parent artery occlusion is a safe way to treat internal carotid giant aneurysms. However, endosaccular treatment still has some problems, i.e., 1) maintaining the balloon's position to preserve the parent artery, 2) balloon migration into the clot, 3) rupture of the aneurysm during or after treatment. Our studies indicate that endosaccular balloon embolization is still a high risk procedure and should be used only in selected cases, until new embolic agents, such as detachable coils, become available.     

Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

Interventional neurovascular techniques for treating patients with intracranial aneurysms are now being performed in selected cases. In certain anatomical locations that are difficult to reach surgically, such as the cavernous portion of the internal carotid artery (ICA), this technique may be especially useful. The procedure is performed from a transfemoral approach, using local anesthesia, thus permitting continuous neurological monitoring. Between 1981 and 1989, 87 patients diagnosed as having an intracavernous aneurysm were treated with endovascular detachable balloon embolization techniques. The patients ranged in age from 11 to 84 years. The presenting symptom was mass effect in 69 cases (79.3%), rupture of a preexisting aneurysm resulting in a carotid-cavernous sinus fistula in eight cases (9.2%), trauma resulting in a cavernous pseudoaneurysm in seven cases (8.0%), and hemorrhage in three cases (3.4%). Therapeutic occlusion of the ICA across or just proximal to the aneurysm neck was performed in 68 patients (78.2%). Since 1984, with the development of a permanent solidifying agent (2-hydroxyethyl methacrylate) to fill the balloon, it is now feasible in some cases to guide the balloon directly into the aneurysm and preserve the parent artery; this was achieved in 19 cases (22%). Follow-up examination has demonstrated complete thrombosis with partial or total alleviation of symptoms in all patients with therapeutic occlusion of the parent vessel. Of the 19 patients with preservation of the parent artery, follow-up studies have demonstrated total exclusion in 12 cases (63%) and subtotal occlusion of greater than 85% in seven cases (37%), with clinical improvement in all cases. Complications from therapy included transient cerebral ischemia during or after therapy requiring volume expansion in seven cases, embolic symptoms requiring antiplatelet medication in two cases, and stroke in four cases; there were no deaths. Detachable balloon embolization therapy, particularly for large and giant symptomatic aneurysms of the cavernous ICA, can be an effective mode of treatment.     

A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report

BACKGROUND: Aneurysms of the posterior circulation are challenging lesions to neurosurgeons, despite improvements in microsurgical techniques and advances in skull base approaches. We present a rare case of a posterior cerebral artery (PCA)-posterior communicating artery (PcomA) junction aneurysm associated with bilateral internal carotid artery (ICA) occlusion successfully treated with an endovascular procedure. CASE DESCRIPTION: A 57-year-old female presented with sudden onset of severe headache and loss of consciousness. CT scan showed diffuse subarachnoid hemorrhage and acute hydrocephalus. The patient developed severe neurogenic pulmonary edema and shock. Although her neurogenic pulmonary edema did not resolve, she recovered from shock. However, her general condition was so critical and her vital signs so unstable, that direct surgery under general anesthesia was considered too risky. A cerebral angiogram showed complete occlusion of both internal carotid arteries without any Moyamoya vessels. A saccular aneurysm located at the right PCA-PcomA junction was seen. To obliterate the aneurysm and prevent rerupture, the patient underwent coil embolization via an endovascular approach under sedation with local anesthesia. The balloon remodeling technique was useful to prevent occlusion of parent arteries. Finally, four interlocking detachable coils (IDC) with a total length of 44 cm were used to completely obliterate the aneurysm using the balloon remodeling technique. The patient made a full recovery after treatment and the aneurysm remained obliterated 2 years after coil embolization. CONCLUSIONS: We emphasize the advantages of the endovascular approach for the patient in critical condition. We believe that this is the first report of a PCA-Pcom junction aneurysm associated with bilateral ICA occlusion without moyamoya disease.     

Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck.

The authors describe the case of a patient with a symptomatic giant aneurysm of the posterior communicating artery (PCoA) associated with bilateral idiopathic occlusion of the internal carotid artery (ICA). The presence of severe tortuosity of the vertebral arteries (VAs), both at their origin from the subclavian artery and at the level of the third segment, impeded navigation of the catheter for embolization of the aneurysm with Guglielmi detachable coils (GDCs). A direct surgical approach was considered to be a high-risk procedure because of the bilateral occlusion of the ICAs and the size of the aneurysm. The following therapeutic strategy was therefore adopted: 1) balloon occlusion test of the left VA; 2) vertebro-vertebral bypass with saphenous vein graft to provide a pathway for subsequent embolization; 3) ICA-left middle cerebral artery bypass to ensure blood flow in the event that embolization resulted in closure of the PCoA; and 4) GDC embolization of the aneurysm via the posterior circulation graft to ensure complete exclusion of the lesion from the arterial circulation and preservation of the PCoA. At 3-month follow-up review the patient did not present with any neurological deficits; at 1-year control examination, magnetic resonance (MR) imaging and MR angiography both confirmed complete exclusion of the aneurysm and patency of the two bypasses.     

Angiographic classification for the selection of treatment of spontaneous carotid-cavernous sinus fistula

Sixteen cases of spontaneous carotid-cavernous sinus fistula treated in our clinic were angiographically classified into four types, based on the report by Barrow et al; Type A: direct shunts between the internal carotid artery (ICA) and the cavernous sinus (CS), Type B: dural shunts between meningeal branches of the ICA and the CS, Type C: dural shunts between meningeal branches of the external carotid artery (ECA) and the CS, type D: dural shunts between meningeal branches of both the ICA and ECA and the CS. Our fundamental modality of treatment for each type was described as follows; detachable balloon occlusion of fistula was performed for Type A immediately after the diagnosis was confirmed. On the other hand, conservative treatment was selected at first routinely for Type B, C and D with administration of hemostatic agents, control of the blood pressure and Matas test for a certain period. This selection was made because the latter three types sometimes showed a high rate of spontaneous regression of symptoms. Only when no improvement was obtained by conservative therapy with Type B, C and D, the following treatments were adopted respectively; Type B: irradiation----detachable balloon occlusion of fistula, Type C: embolization through ECA, Type D: embolization through ECA----irradiation.     

Detachable balloon embolization therapy of posterior circulation intracranial aneurysms

Treatment of complex and surgically difficult intracranial aneurysms of the posterior circulation is now being performed with intravascular detachable balloon embolization techniques. The procedure is carried out under local anesthesia from a transfemoral arterial approach, which allows continuous neurological monitoring. Under fluoroscopic guidance, the balloon is propelled by blood flow through the intracranial circulation and in most cases, can be guided directly into the aneurysm, thus preserving the parent vessel. If an aneurysm neck is not present, test occlusion of the parent vessel is performed and, if tolerated, the balloon is detached. Twenty-six aneurysms in 25 patients have been treated by this technique. The aneurysms have involved the distal vertebral artery (five cases), the mid-basilar artery (six cases), the basilar artery (11 cases), and the posterior cerebral artery (four cases). The aneurysms varied in size and included three small (less than 12 mm), 15 large (12 to 25 mm), and eight giant (greater than 25 mm). Fifteen patients (60%) presented with hemorrhage and 10 patients (40%) with mass effect. In 17 cases (65%) direct balloon embolization of the aneurysm was achieved with preservation of the parent artery. In nine cases (35%), because of aneurysm location and size, occlusion of the parent vessel was performed. Complications from therapy included three cases of transient cerebral ischemia which resolved, three cases of stroke, and five deaths due to immediate or delayed aneurysm rupture. The follow-up period has ranged from 2 months to 43 months (mean 22.5 months). In cases where posterior circulation aneurysms have been difficult to treat by conventional neurosurgical techniques, intravascular detachable balloon embolization may offer an alternative therapeutic option.     

Treatment of unclippable giant posterior cerebral artery aneurysms with detachable balloons--report of three cases.

Three patients presented with rare giant posterior cerebral artery aneurysms, clinically manifesting as cerebral ischemia, mass effect, and subarachnoid hemorrhage. All aneurysms were partially thrombosed, originated at the P2 segment, and possessed broad necks. Surgical neck clipping was difficult but proximal occlusion of the parent artery was feasible. Aneurysm occlusion sparing the parent artery was attempted in all cases, but failed because the detachable balloon did not successfully block the aneurysmal neck. All patients tolerated test occlusion at the P2 segment, so the parent artery was occluded proximally with detachable balloons, leaving the important perforating arteries unaffected. Two transient ischemic attacks were associated with the procedure. Where surgical treatment is unusually difficult, and proximal ligation or trapping just feasible, embolization with detachable balloons is an acceptable substitute.     

Endovascular Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Malformations Presenting as Pulsatile Tinnitus

Transverse-sigmoid sinus dural arteriovenous malformations (DAVM) are uncommon vascular lesions for which complete cure may be difficult to obtain. A wide variety of treatments for these lesions include observation, arterial compression, surgical resection, and endovascular embolization. We propose that transverse-sigmoid sinus DAVM can be completely cured by occluding the ipsilateral dural sinus with detachable balloon and Guglielmi detachable coils (GDC) coils before arterial feeder embolization with histoacryl. Three patients who presented with pulsatile tinnitus and normal magnetic resonance imaging (MRI) studies underwent angiography, which demonstrated transverse-sigmoid sinus DAVM. All three patients wer treated with retrograde transvenous sinus embolization with complete occlusion of the transverse-sigmoid sinus with detachable balloons and GDC coils with preservation of the vein of Labbé. Subsequently, the various feeders from the external carotid artery were embolized. The tentorial arteries arising from the ipsilateral internal carotid arteries were not embolized in any of the cases, which were still contributing to the DAVM. Complete cure with thrombosis of the tentorial branch of the internal carotid artery (ICA) was seen on follow-up angiogram 1 day after embolization in one patient and on 4-week and 6-week follow-up angiograms in the other two patients. Complete occlusion of the transverse sinus proximal to the vein of Labbé, in spite of incomplete arterial feeder embolization, can result in complete cure of the transversesinus dural AVF if adequate time is given for the remaining feeders to occlude, once the fistula is obliterated.