海绵窦造影的颈动脉－海绵窦瘘及其并发症中的诊断和治疗意义

目的：了解颈动脉-海绵窦瘘（carotid-cavernous fistula，CCF）的血流动力学变化和颈内动脉海绵窦段及其周围静脉窦和静脉的病理改变，为制定更为合理的治疗方案提供依据。方法：1990年4月-1999年4月共收治CCF患124例，28例施行眼上静脉（superior ophthalmic vein，SOV）海绵窦造影，其中A型17例，B型1例，D型10例。结果：海绵窦造影显示，海绵窦接近正常12例（42.86%），其中海绵窦3例，网状海绵窦9例。海绵窦扩大16例（57.14%），包括局限性扩张呈静脉湖状14例，其中海绵窦囊性占位5例，即囊中囊表现，提示存在外伤性动脉瘤；海绵窦分隔2例。辅助动脉造影检查发现，CCF合并同侧颈动脉闭塞2例，颈动脉例，合并外伤性动脉瘤5例，其中2例发生严重鼻出血。28例均经眼上静脉入路或眼上静脉 动脉入路闭塞CCF及假性动脉瘤，治疗效果良好。结论：眼上静脉-海绵窦造影与颈动脉造影结合，于动脉外闭塞CCF瘘口或闭塞海绵窦瘘，可提高CCF治疗的成功率并保持载瘘动脉的通畅率，有助于CCF合并颈内动脉海绵窦段损伤及外伤性动脉瘤的诊断与治疗。     

经皮血管腔内栓塞治疗外伤性颈内动脉海绵窦瘘

目的 回顾性分析外伤性颈内动脉海绵窦瘘（CCF）经血管内途径栓塞治疗的方法、疗效和并发症的处理。方法 25例患者均为外伤后出现不同程度的搏动性患侧突眼等症状，术前常规行CT／CTA或MR／MRA检查．并均经DSA造影证实。20例患者行经颈内动脉途径栓塞治疗，栓塞材料包括可脱球囊和（或）可控脱弹簧圈；2例患者行经眼上静脉途径采用微弹簧圈栓塞治疗；3例患者经颈内动脉途径应用可脱球囊和（或）可控脱弹簧圈栓塞失败后，经颈内动脉途径置入带膜支架成功闭塞瘘口。结果 25例患者均为单侧CCF，其中22例为Ⅰ型CCF．3例为Ⅱ型CCF。眼上静脉为主要的扩张引流静脉，其他的静脉引流还有基底静脉、侧裂静脉、眼下静脉、岩上窦、岩下窦以及对侧海绵窦等。术后造影见所有25例患者的患侧颈内动脉均保持通畅。20例经颈内动脉途径栓塞治疗的患者中14例栓塞治疗后瘘口完全闭塞，4例患者瘘口残留．1例术后经压颈试验1周瘘口完全闭塞．另2例患者1个月后再次经颈内动脉途径使用DCS成功栓塞瘘口，仅1例瘘口残留患者术后第2天出现硬膜下出血和颅内高压症状，后转入神经外科行开颅减压和结扎止血治疗。2例患者术后2个月复发，再次经颈内动脉途径采用可脱微弹簧圈栓塞后瘘口完全闭塞。2例患者行经眼上静脉途径应用弹簧圈栓塞治疗，其中1例患者栓塞后瘘口少量残留，1个月后再次经颈内动脉途径使用可控脱微弹簧圈（DCS）成功栓塞瘘口。3例患者经颈内动脉途径带膜支架植入术治疗．CCF瘘口完全闭塞。术后造影见所有25例患者的患侧颈内动脉均保持通畅。结论 经血管腔内栓塞治疗颈内动脉海绵窦瘘具有创伤小、疗效可靠和可重复操作的特点，是目前治疗CCF的首选方法：及时、有效地处理术后复发可避免严重并发症的发生。     

海绵窦造影在颈动脉-海绵窦瘘及其并发症中的诊断和治疗意义

目的 了解颈动脉一海绵窦瘘(carotid-cavernous fistula,CCF)的血流动力学变化和颈内动脉海绵窦段及其周围静脉窦和静脉的病理改变,为制定更为合理的治疗方案提供依据。方法 1990年4月～1999年4月共收治CCF患者124例,28例施行眼上静脉(superior ophthalmic vein,SOV)海绵窦造影,其中A型17例,B型1例,D型10例。结果 海绵窦造影显示,海绵窦接近正常者12例(42.86％),其中海绵窦狭窄3例,网状海绵窦9例。海绵窦扩大者16例(57.14％),包括局限性扩张呈静脉湖状14例,其中海绵窦囊性占位者5例,即囊中囊表现,提示存在外伤性动脉瘤;海绵窦分隔2例。辅助动脉造影检查发现,CCF合并同侧颈动脉闭塞者2例,颈动脉狭窄3例,合并外伤性动脉瘤5例,其中2例发生严重鼻出血。28例均经眼上静脉入路或眼上静脉+动脉入路闭塞CCF及假性动脉瘤,治疗效果良好。结论 眼上静脉-海绵窦造影与颈动脉造影结合,于动脉外闭塞CCF瘘口或闭塞海绵窦瘘,可提高CCF治疗的成功率并保持载瘘动脉的通畅率,有助于CCF合并颈内动脉海绵窦段损伤及外伤性动脉瘤的诊断与治疗。     

覆膜支架治疗完全盗血型颈动脉海绵窦瘘

目的探讨覆膜支架用于血管内治疗完全盗血型颈动脉海绵窦瘘(CCF)的效果。方法自2008年7月至2009年5月,应用覆膜支架对6例完全盗血型CCF进行血管内治疗。结果5例患者覆膜支架均成功释放于瘘口处,瘘口消除并保持颈内动脉通畅,1例因颈内动脉海绵窦段过度迂曲无法到达理想位置。全组无手术相关并发症发生。术后3个月时,4例患者获脑血管造影随访,显示颈内动脉通畅,但1例患者颈外动脉海绵窦瘘较术后即刻更加明显。结论对于完全盗血型CCF,覆膜支架血管内治疗是其可供选择的有效治疗方法之一。     

覆膜支架在颈内动脉海绵窦段病变治疗中的应用

目的 评价应用覆膜支架治疗颈内动脉海绵窦段病变的价值.方法 采用覆膜支架治疗11例颈内动脉海绵窦段病变,其中颈内动脉海绵窦瘘5例,颈内动脉海绵窦段动脉瘤6例,术后1年行全脑血管造影随访和临床随访.结果 11例患者中,成功应用覆膜支架治疗9例,成功置入覆膜支架的9例患者,术后即刻血管造影显示病变完全消失,临床症状逐渐好转,无手术相关并发症,术后1年行全脑血管造影复查8例,结果显示病变消失,责任动脉均保持通畅.结论 覆膜支架在处理颈内动脉海绵窦段动脉瘤或颈内动脉海绵窦瘘方面,有治疗成功率高,疗效好,并发症少,复发率低等特点,值得推广.     

颈内动脉海绵间窦瘘1例

颈内动脉海绵窦瘘（carotid　cavernous　fistula,CCF）系指海绵窦段的颈内动脉,或其在海绵窦段内的分支血管破裂,与海绵窦之间形成异常的动、静脉沟通,因外伤引起者占75％～85％。临床上所见外伤性颈内动脉-海绵窦瘘（traumatic　carotid　cavernous　fistu-la,TCCF）多为患侧颈内动脉通过瘘口充盈同侧海绵窦或同时通过海绵间窦充盈两侧海绵窦。而患侧颈内动脉通过海绵间窦只充盈对侧海绵窦,不充盈同侧海绵窦,则较为少见。国内尚未见专文报道此种颈内动脉海绵窦间窦瘘（carotid　intercavernous　fistu-la）。我们最近发现1例,现报告如下。1　资料     

经岩下窦静脉入路治疗颈动脉海绵窦瘘

目的探讨经岩下窦静脉入路治疗颈动脉海绵窦瘘(CCF)的疗效。方法经股静脉-岩下窦入路到达病变侧海绵窦，用各种弹簧圈如GDC、EDC、Matrix、FreeCoil和丝线等多种材料填塞海绵窦，同时闭塞瘘口。结果经股静脉-岩下窦入路对18例、21侧海绵窦进行了栓塞治疗。16例治疗后造影显示海绵窦和瘘口完全闭塞，无静脉引流；2例虽将海绵窦瘘口密实填塞，但仍有低流量翼丛引流，术后临床症状减轻，压颈1周后症状消失。栓塞术后病人主要表现为头痛和呕吐。2例术前伴有动眼神经麻痹病人，栓塞治疗后其他症状消失，但动眼神经功能未恢复。1例栓塞术后出现一过性外展神经麻痹，后自行恢复。有7例为外伤性，经动脉途径球囊栓塞后复发，或经弹簧圈治疗未成功。有11例为自发性，除3例岩下窦引流不明显，经硬导丝努力打通该通路，余者岩下窦均引流明显，导丝较易通过。随访3个月至24个月，6例病人术后3个月回医院行全脑血管造影检查，未发现复发；余者因术后无症状未回医院复查。结论经岩下窦静脉入路治疗CCF安全有效，对于外伤性CCF，为经动脉入路失败后治疗该病的主要治疗方法，而对于自发性CCF，应作为首选治疗。     

外伤性颈动脉海绵窦瘘的血管内治疗

目的 探讨外伤性颈动脉海绵窦瘘的血管内治疗的技术特点。方法 对于不同的病例采用了不同的方法．包括海绵窦瘘口球囊栓塞，保持颈内动脉通畅，以及连同瘘口闭塞的颈内动脉闭塞术。对于动脉途径难以进行的病例采取了经静脉途径弹簧圈的栓塞结果 53例球囊闭塞瘘口且保持颈内动脉通畅。14例连同瘘口闭塞颈内动脉。3例通过静脉途径栓塞满意。结论 外伤性颈动脉海绵窦瘘应首选血管内栓塞治疗。一般情况下海绵窦瘘均表现为良性过程．应力争解剖治愈，不可轻易牺牲颈内动脉。     

面静脉-眼上静脉入路填塞海绵窦

目的评价经面静脉-眼上静脉入路填塞海绵窦治疗颈动脉海绵窦瘘（CCF）的有效性。方法经股静脉-面静脉-眼上静脉入路到达患侧海绵窦，用GDC或EDC，游离弹簧圈，真丝线段等多种栓塞材料填塞海绵窦，同时闭塞瘘口。面静脉插管困难者，在下颌角附近切开皮肤显露面静脉，直视下穿刺面静脉放置相应导管，再经眼上静脉到达患侧海绵窦并将其填塞。结果经面静脉-跟上静脉入路对14例，16侧海绵窦进行了栓塞治疗，其中5例为外伤性、直接CCF（A型），经动脉途径球囊栓塞后复发，或微弹簧圈栓塞未能成功，或经岩下窦入路未能成功，9例为自发性、间接CCF（D型8例，C型1例）。13例经股静脉-面静脉-眼上静脉途径，1例通过直视下面静脉穿刺。11例栓塞治疗后即刻造影显示瘘消失，2例残留低流量的岩下窦引流，另有1例在微导管进入面静脉后，而静脉痉挛闭塞，未能继续进行栓塞治疗，造影仍见瘘存在，但眼静脉出现明显的造影剂滞留。1例A型CCF在球囊栓塞后出现外展神经麻痹，经面静脉-眼上静脉栓塞后亦无改善。因面静脉痉挛闭塞未能栓塞成功者，于术后即感眼部症状加重，但第2天感症状缓解，术后第21天症状明显改善，造影检查发现瘘门已经消失，术后1个月病人眼部症状完全消失。其他病例在栓塞术后眼部症状明显改善，最后消失。随访3个月至21个月未见复发。2例残留瘘口者，1例于3个月和12个月进行2次造影复查，另1例于3个月造影复查，瘘的流量均无明显变化，因无临床症状未再进行治疗。其他病例未进行造影复查。结论经面静脉-眼上静脉栓塞治疗CCF安全有效，对于A型CCF，可作为经动脉途径治疗失败后的补救措施，而对于B、C、D型CCF，应作为首选治疗。     

外伤性颈内动脉海绵窦瘘合并双侧豆状核变性1例

1 病历摘要 男，26岁。因塌方致头部外伤20d入院。MRI示左侧颈动脉海绵窦瘘（CCF），DSA示左侧CCF，双侧眼静脉淤血扩张（图1）。诊断为左侧外伤性颈内动脉海绵窦瘘（TCCF）。急诊于局麻下行球囊栓塞CCF，术后颅内杂音消失，复查DSA示栓塞成功，颈内动脉及大脑中动脉通畅（图2）。栓塞2d后．逐渐出现吞咽困难，声音嘶哑，双侧肢体呈铅管样强直，肌力Ⅱ级。CT示双侧豆状核区低密度改变；     

Endovascular Graft-Stent Placement for Treatment of Traumatic Carotid Cavernous Fistulas

Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloonexpandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.     

Bilateral carotid cavernous sinus fistula: a case report and review of the literature

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.     

Onyx经动脉入路栓塞创伤性颈内动脉海绵窦瘘

目的 总结运用Onyx栓塞创伤性颈内动脉海绵窦瘘(TCCF)的初步体会,评价其安全性及有效性.方法 对6例明确TCCF的患者(共7侧瘘口),采用球囊封闭颈内动脉瘘口,经颈内动脉将微导管超选进入海绵窦内,通过微导管注射Onyx胶,或联合可脱性球囊及弹簧圈栓塞治疗.结果 除1例双侧TCCF患者在栓塞一侧瘘口后脑血流发生显著变化后,行分期治疗对侧瘘口外,其余5例均一期治疗.术后即刻造影显示一期治疗的6侧瘘口完全闭塞,一侧二期治疗瘘口注胶结束后造影瘘口完全消失,在撤出微导管重新造影时可见少许静脉早显,所有患者颈内动脉保持通畅.4例术前视力障碍患者,术后完全恢复正常;无新发神经系统体征.3例患者术后2-7个月DSA或MRA复查未见瘘口复发.结论 采用球囊辅助经动脉入路Onyx栓塞治疗复杂性TCCF是安全、有效的.     

Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula

BackgroundThe use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow.ObjectiveTo facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device.MethodsHere we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. “Drag and drop” device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula.ResultsTemporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms.ConclusionBalloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.     

经静脉入路栓塞治疗海绵窦区硬脑膜动静脉瘘(附8例报告)

目的探讨经静脉入路栓塞治疗海绵窦区硬脑膜动静脉瘘的方法及效果。方法 8例海绵窦区硬脑膜动静脉瘘患者,分别经股静脉-岩下窦、股静脉-面静脉-眼上静脉、直接开放眼上静脉入路到达病变侧海绵窦,用GDC可控微弹簧圈和ONXY胶等多种栓塞材料填塞海绵窦,同时闭塞瘘口。结果 7例治疗后即刻造影显示海绵窦和瘘口完全闭塞,临床症状消失。1例虽将海绵窦闭塞,但仍残留翼丛引流,临床症状明显缓解,术后行压颈治疗后症状消失。栓塞术后最常见并发症为头痛伴呕吐及外展神经麻痹,1周后缓解。5例患者术后随访3～26个月症状未见复发,其中4例均于术后3月复查DSA未见异常,1例残留瘘口的患者术后6月行脑血管造影复查,显示残留瘘口消失。结论经静脉入路栓塞是治疗海绵窦区硬脑膜动静脉瘘安全、有效的方法。     

Cure of a direct carotid cavernous fistula by endovascular stent deployment

A 53-year-old woman underwent surgical thrombendarterectomy for treatment of artherosclerotic stenoses of her left internal carotid artery (ICA). A Fogarty catheter was used during this operation. The postoperative course was complicated by the development of a sixth cranial nerve palsy, protrusio, chemosis and ciliar injection of both eyes. Digital subtraction angiography showed a direct fistula between the cavernous segment of the left ICA and the cavernous sinus, with early and retrograde opacification of both superior ophthalmic veins. Endovascular occlusion of the fistula was achieved with preservation of the ICA by stent deployment over the rupture site of the ICA, as two detachable balloons could not obliterate the fistula while preserving the ICA patent. Follow-up angiography 7 months after the endovascular treatment confirmed persisting occlusion of the fistula with a patent ICA. Highly flexible porous coronary stents can easily be introduced into tortuous vessels, including the distal ICA. The haemodynamic effects achieved by stent deployment together with two balloons detached in the cavernous sinus may be sufficient to interrupt a direct carotid cavernous fistula.     

Clinical aspects and treatment of spontaneous carotid artery-cavernous sinus fistula

21 patients, who fulfilled the clinical and angiographic criteria of a spontaneous carotid cavernous fistula (CCF), were studied at the Alfried Krupp Hospital, Essen, Germany, between 1980 and 1988. Of these patients, 4 had direct shunts between the internal carotid artery and the cavernous sinus and 17 patients had unilateral or bilateral dural shunts between meningeal branches of the internal and/or external carotid artery and the cavernous sinus. The most common initial symptoms were eye redness, bruit and headache. 6 of 12 patients with double vision had mechanical disorders of eye movement. A rapid irreversible loss of vision occurred in 2 patients. In 9 of 21 patients either progressive visual deterioration, proptosis or severe orbital pain necessitated prompt institution of treatment. All direct fistulas could be occluded by the use of the detachable balloon technique. 5 patients with dural CCF were successfully treated with particle embolization of the external carotid artery blood supply. In dural CCF not requiring emergent treatment, combined carotid artery and jugular vein compression was preferred and resulted in complete cure or sufficient improvement in all but one patient. We recommend this method as the first stage of treatment in dural CCF with uncomplicated course.