外伤性脑动静脉瘘的血管内治疗

目的 探讨外伤性脑动静脉瘘的诊断及鉴别诊断，治疗方法选择及栓塞技术要点。方法 对我院1995至2001年收治的125例外伤性脑动静脉瘘中层得进行全脑血管造影检查，其中颈动脉海绵窦瘘（CCF）98例，硬脑膜动静脉瘘（DAVF）27例，CCF患经股动脉入路以球囊栓塞瘘口93例，经股静脉入路以微弹簧圈栓塞4例，经眼上静脉入路以微弹簧圈栓塞1例；27例DAVF，单纯压迫颈动脉法治疗3例，栓塞治疗24例，24例中，可脱性球囊栓塞脑膜中动脉2例，经动脉途径用聚醋酸乙烯酯（PVA），α-氰基丙烯酸正丁酯（NBCA）胶及冻干硬膜等微粒栓塞21例次，弹簧圈栓塞4例次；经静脉途径弹簧圈栓塞6例次。结果 CCF患95例1次栓塞成功，3例于第一次栓塞后球囊泄漏复发，经再次栓塞治愈，治愈率100%；DAVF患治愈21例，好转5例，无效1例，治愈率为77.8%，总有效率为96.3%。结论 全脑血管造影可明确诊断，正确选择栓塞途径及栓塞材料是手术成功的关键。栓塞治疗首先选择动脉入路，如果动脉入路治疗失败，则可通过股静脉或眼静脉入路。     

经岩下窦栓塞治疗海绵窦区硬脑膜动静脉瘘

目的探讨经岩下窦途径栓塞海绵窦区硬脑膜动静脉瘘(DAVF)的治疗方法。方法回顾性分析15例海绵窦区DAVF病人的临床资料,均经岩下窦插管,以微弹簧圈、ONYX-18胶栓塞海绵窦和瘘口。结果 15例插管成功,DAVF均达到完全致密栓塞。术后多数病人临床症状缓解或消失;术后并发颞叶梗死1例,致左侧肢体偏瘫。10例于6~24个月行DSA检查,均无复发。结论经岩下窦途径栓塞可作为海绵窦区DAVF的首选常规治疗方法。     

血管内栓塞治疗海绵窦区硬脑膜动静脉瘘(附18例报告)

目的探讨海绵安区硬脑膜动静脉瘘(DAVF)的血管内栓塞治疗策略。方法对18例海绵窦区DAVF病人根据供血动脉和引流静脉的情况，分别采用经动脉或静脉入路进行血管内栓塞治疗。结果共行19次栓塞。完全闭塞11例，部分闭塞7例。随访3个月～5年，治愈病例无复发，好转病例无恶化、结论血管内栓塞是海绵窦区DAVF较为理想的治疗方法。     

海绵窦区硬脑膜动静脉瘘的栓塞治疗

目的探讨海绵窦区硬脑膜动静脉瘘的有效治疗方法。方法11例海绵窦区硬脑膜动静脉瘘病人经动脉途径,采用真丝线段或真丝线段加NBCA胶栓塞治疗。其中3例同时经静脉途径采用微弹簧圈(GDC、MDS和游离弹簧圈)或弹簧圈加真丝线段栓塞海绵窦结果本组。11例中有10例临床治愈(症状消失),其中8例解剖治愈(瘘口消失);1例症状明显缓解。结论血管内栓塞是海绵窦区硬脑膜动静脉瘘有效安全的治疗方法。     

经静脉入路栓塞治疗横窦-乙状窦区的硬脑膜动静脉瘘

目的评价经静脉入路栓塞治疗横窦-乙状窦区硬脑膜动静脉瘘(DAVF)的安全性和有效性。方法经静脉入路到达患侧的横窦-乙状窦,用微弹簧圈填塞病变静脉窦,同时闭塞瘘口。结果经静脉入路治疗横窦-乙状窦区DAVF共16例。病变累及横窦-乙状窦交界处者11例、横窦者3例、乙状窦者2例。根据Cognard分类,IIa型3例,IIb型1例,IIa b型12例。单纯应用静脉入路7例,经静脉入路前先采用经动脉途径栓塞者8例,经静脉入路栓塞治疗后再经动脉途径栓塞者1例。瘘口完全闭塞13例,瘘口残留3例,但瘘口流量已减少95%以上。15例(94%)在栓塞治疗后临床症状消失,1例栓塞后出现颅内出血死亡,未见其他并发症。随访4～23个月,临床症状无复发。11例行造影复查:3例残留瘘口者2例消失,1例曾行3次造影复查瘘无明显变化,由于无临床症状,未再行栓塞治疗;另外8例造影复查未见复发。结论对于适当选择的横窦-乙状窦区DAVF病例,经静脉入路闭塞病变静脉窦是一种安全有效的治疗方法。     

经动脉途径应用Onyx胶栓塞治疗硬脑膜动静脉瘘(附16例报告)

目的探讨经动脉途径应用Onyx胶栓塞治疗颅内硬脑膜动静脉瘘(DAVF)的可行性及疗效。方法回顾性分析2007年3月至2010年10月收治的16例DAVF患者的临床资料及随访结果。经动脉途径采用Onyx胶栓塞治疗15例,动静脉联合途径1例。结果 16例患者共栓塞17次,栓塞结束即时解剖治愈14例(87.5%),另2例栓塞不全者术后辅以手术治疗。栓塞后出现动眼神经麻痹3例,面部感觉麻木3例,随访1月后症状消失;口咽部疼痛2例,应用糖皮质激素治疗后症状消失。本组无死亡病例。10例患者术后2～24个月复查DSA,1例DAVF复发,9例完全闭塞;6例门诊随访2～24个月均未见复发。结论经动脉途径应用Onyx胶栓塞治疗颅内DAVF是可行、有效的方法,效果良好。     

Onyx胶联合弹簧圈治疗海绵窦区硬脑膜动静脉瘘

目的 探讨经静脉入路Onyx胶联合弹簧圈在海绵窦区硬脑膜动静脉瘘（DAVF）治疗中的临床应用价值。方法 回顾性分析2012年1月至2015年6月收治的16例海绵窦区DAVF的临床资料,均经股静脉-岩下窦路径使用Onyx胶-18/联合弹簧圈栓塞。结果 每例病人弹簧圈用量（4.00±0.73）个,Onyx胶用量（3.43±0.93） ml。岩下窦显影13例,未显影3例;置管成功率100%。16例均治愈。术后7例（43.75%）出现并发症,其中4例为一过性心动过缓,3例为术后头痛,经对症处理均治愈。结论 经静脉入路Onyx胶联合弹簧圈栓塞治疗海绵窦区DAVF疗效肯定,安全性较高。     

Onyx胶栓塞治疗硬脑膜动静脉瘘的初步经验

目的 探讨Onyx胶在硬脑膜动静脉瘘(DAVF)血管内治疗中的应用价值.方法 全麻下经股动脉穿刺插管,造影证实病变后,微导管超选择插管到达瘘口附近,用Onyx-18栓塞治疗DAVF 10例.其中Cognard Ⅰ、Ⅱ型者6例,Ⅲ型、Ⅳ型者4例;单纯型7例,复合型3例.结果 10例DAVF患者,共行14次栓塞治疗,7例为一次栓塞,2例为二次栓塞,其中1例因DAVF供血动脉复杂,行三次栓塞治疗.最终栓塞达80%以上者8例,其中完全栓塞6例;50%～80%栓寨者2例.本组病例无并发症发牛.结论 Onyx胶栓塞是治疗DAVF较为安全、有效的方法.     

弹簧圈辅助Onyx 18胶栓塞自发性颈动脉海绵窦瘘临床分析

目的探讨应用Onyx 18胶结合弹簧圈栓塞自发性颈动脉海绵窦瘘的疗效。方法分析我院2例自发性CCF患者应用Onyx 18胶结合弹簧圈栓塞的手术过程、随访结果,并讨论其疗效。结果 1例采用颈外动脉-上颌动脉-脑膜中动脉-海绵窦入路成功栓塞CCF,瘘口完全闭塞,出院时症状消失,完全治愈;另1例采用颈外动脉-上颌动脉-脑膜中动脉-海绵窦开口入路成功栓塞CCF,术后造影评估:瘘口次全闭塞,出院时症状改善,院外行颈总动脉按压,随访2个月后临床症状消失。2例均随访6个月,未见症状复发。结论经颈外动脉-上颌动脉-脑膜中动脉途径,较易到达海绵窦内,海绵窦内栓塞为闭塞CCF瘘口的理想部位,Onyx 18胶能在海绵窦中形成良好弥散,结合弹簧圈的应用有利于瘘口的闭塞,减少危险吻合的发生率。海绵窦内栓塞空间较大,需要材料较多,费用昂贵,海绵窦瘘口处栓塞并结合术后颈总动脉按压同样能治愈部分单纯CCF病人。     

自发性颈动脉海绵窦瘘的介入治疗

目的 探讨自发性颈动脉海绵窦瘘的诊治方法。方法 9例单纯颈内动脉供血,其中6例采取球囊瘘内闭塞术,3例采用瘘口一同闭塞的颈内动脉闭塞术。11例采用微导管超选择性插管,行瘘的供血动脉及瘘口栓塞。栓塞后7例仍有供血者3例经压颈1个月瘘口消失,2例疗效不满意,患者未再来治疗,2例采取经岩下窦途径和经眼静脉途径。1例单纯由颈内动脉脑膜支供血的行γ刀治疗。结果 13例栓塞后造影瘘口完全闭塞,7例栓塞后造影瘘口有显影,术后采取压迫患侧颈总动脉1个月,半年后3例造影瘘口消失,2例疗效不满意,失去随访,2例经眼静脉、岩下窦栓塞海绵窦取得成功。γ刀治疗1例,症状消失。19例随访6个月未见瘘口再通。结论 介入栓塞是治疗自发性颈动脉海绵窦瘘行之有效的方法。     

Transarterial Onyx embolization of sagittal sinus dural arteriovenous fistulae

We report four patients (1 woman and 3 men) with sagittal sinus dural arteriovenous fistulae (DAVF) treated by Onyx embolizations via the middle meningeal artery. Anatomic cure and clinical cure were achieved in all the patients. The fistulae were located in the middle and posterior parts of the sagittal sinus. By Cognard classification the fistulae were: type I - one, type IIb - one, and type IV -two. All these four patients underwent a clinical and angiography follow-up, which confirmed complete cure. Based on this experience, we hypothesize that sagittal sinus DAVFs can be cured using a transarterial endovascular approach.     

Treatment outcomes of intracranial dural arteriovenous fistulas of the transverse and sigmoid sinuses from a single institute in Asia

Intracranial dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses (TSS) are rare in Asian populations. This study sought to evaluate the treatment outcomes of intracranial TSS DAVFs at a single Asian institute. Between 1989 and 2007, 122 patients presented to the Seoul National University Hospital with intracranial DAVFs; we performed a retrospective analysis of the 38 patients (31.1%) with TSS DAVFs. The common clinical presentations were headache (44.7%), tinnitus (39.5%), and intracranial hemorrhage (26.3%), and 71.1% had Borden type II or III lesions. Two patients were conservatively managed, two underwent surgery, and 34 were treated endovascularly with transarterial embolization (TAE), transvenous embolization (TVE), or both. The complete occlusion rate immediately after treatment was 50%. Of the 31 patients (81.6%) who underwent follow-up angiography, initial complete occlusion was achieved in 51.6%, and, at the last follow-up, the complete occlusion rate was 64.5%, with the surgery and TVE groups achieving 100% occlusion. The clinical cure rate was 34.2%, and 86.8% of patients had a favorable clinical outcome. However, all patients in both the surgery and TVE groups achieved a favorable clinical outcome. Four (26.7%) of 15 lesions with initially partial embolization showed delayed occlusion. Five patients (13.2%) exhibited clinical or angiographic signs of recurrence, and five patients had permanent complications. TSS DAVFs were less common than cavernous sinus DAVFs, unlike in Western countries, but the angiographic and clinical characteristics of TSS DAVFs were similar to those in Western countries. TSS DAVFs were successfully managed with different modalities, but both surgery and TVE were superior to conservative management or TAE.     

Endovascular treatment for dural arteriovenous fistulas at the jugular foramen

We report the technique and results of the endovascular treatment of jugular foramen dural arteriovenous fistulas (DAVFs) in 4 (3 men and 1 women, mean age 50.75 years) symptomatic patients. The jugular foramen DAVFs accounted for 5.9% of intracranial DAVFs. Three patients presented with pulsatile tinnitus and 1 patient presented with intracranial hemorrhage. Angiography demonstrated an AV fistula at the jugular foramen, mostly arising from the middle meningeal, ascending pharyngeal and vertebral arteries with direct drainage to the internal jugular vein. All patients underwent transarterial embolization using Onyx-18. Complete shunt obliteration was achieved in 3 patients; and shunt reduction, in 1 patient, who was cured with additional surgery. Our study suggests that in jugular foramen DAVF transarterial embolization with Onyx should be considered when access is available.     

前颅窝底硬脑膜动静脉瘘的外科治疗

目的 分析12例前颅窝底硬脑膜动静脉瘘(dural arteriovenous fistulas, DAVFs)外科治疗方法和结果,探讨治疗的必要性及如何提高疗效.方法 行六血管全脑血管造影,结合CT、MRI,分析影像学特点,全麻下进行经颅手术夹闭瘘口或血管内栓塞治疗.3例经眼动脉分支供血动脉到接近瘘口处用10%～20%的NBCA胶栓塞,1例经颌内动脉分支接近瘘口用ONYX胶栓塞,2例经颌内动脉以PVA栓塞;6例(包括1例经静脉入路血管内治疗失败后)经前颅窝底入路用动脉瘤夹直接夹闭位于筛板的瘘口的静脉端.结果 6例前颅窝底DAVFs直接手术夹闭瘘口治愈;4例经动脉入路栓塞治愈;2例经动脉入路栓塞治疗后好转.结论 前颅窝底DAVFs直接手术效果好;经动脉入路栓塞到瘘口静脉端也可治愈,但需防止并发症.     

Endovascular angioplasty and stent placement in venous hypertension related to dural arteriovenous fistulas and venous sinus thrombosis

Venous hypertension in lateral sinuses resulting from dural arteriovenous fistula (DAVF) and venous sinus thrombosis (VST) can manifest with severe neurological deficits, such as infarction or intracerebral hemorrhage. It has been proved that venous hypertension plays a significant role in the evolution and progression of DAVF and VST. The definite treatment in complicated conditions such as multiple DAVFs or multiple sinus occlusions is still unknown. Traditional transarterial embolization, transvenous embolization or radiosurgery alone has limited effects on these conditions. We reported one case with venous hypertension presenting with severe neurological symptoms. The case had quick clinical recovery after correction of venous hypertension by endovascular angioplasty and stent placement in occluded lateral sinuses. Accordingly, we propose this method can be an ideal treatment option either in single or staged therapy of venous hypertension related to DAVFs and VST.     

Endovascular embolization of a recurrent cervical giant cell neoplasm using N-butyl 2-cyanoacrylate

Pre-operative endovascular embolization of spinal giant cell tumors (GCTs) has been an effective strategy to reduce blood loss during surgical resection. Traditionally, spinal GCTs have been embolized with polyvinyl acetate (PVA) particles. We present the pre-operative embolization of a recurrent cervical GCT with N-butyl 2-cyanoacrylate (NBCA) rather than PVA. The patient was a 17-year-old female who, 3 months prior, had undergone a surgical resection of a cervical GCT without pre-operative embolization. She returned with tumor recurrence in the approximate location. Resection was recommended, and pre-operative embolization was requested. The tumor was embolized with NBCA. Post-embolization angiography demonstrated significantly decreased tumor “blush” and a significant reduction of the vascular supply. This is the first reported use of NBCA for the pre-operative embolization of a cervical GCT. The benefits of NBCA over PVA particles include superior penetration, permanent tumor embolization and lower exposure to radiation due to shorter procedure time.     

11例非Galen静脉脑动静脉瘘的血管内栓塞治疗

作者报告了1979年至1995年治疗的11例非Galen静脉的脑动静脉瘘(AVF),对其诊断标准及治疗原则进行探讨.1例以球囊栓塞失败后行手术夹闭供血动脉;8例以IBCA/NBCA栓塞治疗,其中1例经3次栓塞缩小静脉球后手术切除残留的动静脉畸形(AVM);2例以弹簧圈栓塞瘘口.结果:动静脉瘘100%闭塞8例,恢复良好.8例中的6例脑血管造影复查,未见复发;植物生存1例;死亡2例.对治疗原则,血管内栓塞进行了讨论,认为栓塞材料首选弹簧圈.     

Clinical characteristics of dural arteriovenous fistula.

Intracranial dural arteriovenous fistula (DAVF) is an uncommon neurosurgical condition; in particular, it has been infrequently reported in Korea. To understand the general clinical characteristics of DAVFs, the authors reviewed 53 cases and analyzed factors affecting DAVF hemorrhage of and treatment outcome. Since 1980 we have encountered 480 pial and 53 DAVFs, a ratio of 9.1 to 1. The age of these patients ranged from 1 month to 71 years, the most common being in the 6th decade, and females exceeded males by 1.65 to 1. All lesions except three were single, and symptoms were related to location and the venous drainage pattern. The most common location was the cavernous sinus, accounting for about 64% of cases, with the result that the most common clinical symptoms of DAVFs were ocular, namely proptosis and chemosis. The next was tinnitus also found in transverse-sigmoid sinus DAVFs. Intracranial hemorrhage was seen in eight cases,(15%) the primary cause of hemorrhage was retrograde intracranial venous drainage (P=0.017), and one hemorrhage was observed in cases with no intracranial venous drainage. Intracranial hemorrhage was more frequently in transverse-sigmoid than cavernous sinus DAVFs (P=0.049), and this proved to be so even where there was intracranial venous drainage. However, two of 34 patients with cavernous DAVFs became blind in one eye, demonstrating that in such patients, the clinical course could be aggressive. Thirteen patients were treated conservatively. The conservative treatment group was comprised of 13 patients, two of three patients with transverse-sigmoid sinus DAVF expired, and 7 of 10 with cavernous sinus DAVF experienced a clinical improvement or cure. Surgical excision was performed in only two patients. A total of 39 patients underwent embolization; clinical cure was achieved in 13, improvement of symptoms in 12, an unchanged or aggravated result occurred in 9, one died, and four were lost to follow up. During intervention, there was one hemorrhagic complication, owing to obstruction of the venous outflow with embolic materials.In this study, the most common location of DAVFs was the cavernous sinus. The cortical venous drainage remains the primary determinant of intracranial hemorrhage. Common indications for treatment include hemorrhage and neurological deficit. Endovascular treatment is preferred in the majority of cases except tentorial DAVF. The goal of embolization in cavernous DAVF is the alleviation of symptoms, not angiographic cure. But transverse-sigmoid sinus DAVF with venous restriction and leptomeningeal drainage should be treated aggressively.     

Intra-operative N-butyl cyanoacrylate embolization arrest of uncontrollable hemorrhage during meningioma resection

During the surgical resection of a convexity meningioma in a 63-year-old woman, an uncontrollable active hemorrhage from the operative bed was arrested with microcatheter N-butyl cyanoacrylate (NBCA) embolization after superselective angiography. To date, an uncontrollable neurosurgical intraprocedural hemorrhage terminated by NBCA embolization has not been previously reported. The embolization risk relative to the benefit needs to be carefully considered prior to the surgical removal of a meningioma. This report emphasizes the potential value of embolization with NBCA for arresting active bleeding intraoperatively.