创伤性颈内动脉假性动脉瘤的血管内治疗

目的 探讨载瘤动脉闭塞、弹簧圈栓塞以及支架技术治疗颅内创伤性颈内动脉假性动脉瘤(pseudoaneurysm,PSA)的适应证及其疗效.方法 本组6例患者,3例海绵窦段PSA合并颈内动脉海绵窦痿(carotid-cavernous fistula,CCF),2例单纯颈内动脉PSA,1例CCF球囊栓塞后复查显示PSA.球囊闭塞CCF及创伤性颈内动脉PSA 1例,弹簧圈栓塞3例,颈内动脉球囊闭塞2例.根据6例患者的临床表现、影像学资料、治疗方法选择、临床疗效、随访资料以及文献,分析三种治疗方式的适应证.结果 本组患者无手术相关并发症发生,无脑缺血并发症.术后无鼻出血发生,3例眼球突出回复,1例随访半年视力改善,3例颅内杂音消失,3例瞳孔缩小,复查数字减影血管造影(DSA)未见PSA复发.结论 血管内治疗是治疗颈内动脉PSA的首选,合并CCF时可行球囊闭塞或载瘤动脉闭塞.对单纯窄颈者予以弹簧圈栓塞,对宽颈的采用支架技术结合弹簧圈栓塞,而位于颈内动脉岩段可选择带膜支架.

Abstract：

Objective To investigate the indication and result of parental artery occlusion, embolization with coils, stents in treatment of the traumatic carotid artery pseudoaneurysm. Methods There were six patients with traumatic carotid artery pseudoaneurysm including three patients of cavernous pseudoaneurysm combined with carotid-cavernous fistula (CCF), two with simple traumatic carotid artery pseudoaneurysm and one with traumatic carotid artery pseudoaneurysm that was found after CCF embolization with detachable balloon. The treatment included balloon occlusion for CCF and traumatic carotid pseudoaneurysm in one patient, coil embolization in three and intenal carotid artery balloon occlusion in two. The Clinical manifestations, imaging data, choice of treatment, clinical efficacy, follow-up data and literatures were analyzed to discuss the indications for three treatments. Results There was no cerebral ischemia or surgically-related complication. No epistaxis occurred. The eyeball protrusion restoration was found in three patients and intracranial bruit vanishing in three. Vision was improved one patient after half a year follow-up. The pupils shrank in three patients during follow - up. Digital subtraction angiography (DSA) showed no recurrence of pseudoaneurysm. Conclusions Endovascular treatment is the preferred choice of treatment for traumatic carotid artery pseudoaneurysm. The occlusion or parent artery balloon occlusion can be used when the pseudoaneurysm is combined with CCF. Coil embolization can be used for shoes with narrow neck, stent technology combined with coil embolization for those with wide neck and the covered stent for the rock section of the internal carotid artery.     

Endovascular treatment of high-flow carotid cavernous fistulas by stent-assisted coil placement

BACKGROUND AND PURPOSE: Endovascular techniques are the methods of choice for the treatment of patients with carotid cavernous fistulas. We report our experience using stent-assisted coil placement for treatment of patients with high-flow fistulas that are associated with severe laceration of the internal carotid artery. METHODS: In a retrospective review of an internal endovascular therapy database covering the interval between October 2001 and October 2003, we identified a total of 5 patients presenting with 6 high-flow type A carotid cavernous fistulas (one had a bilateral fistula) that were associated with severe laceration of the internal carotid artery. All were treated first with stenting of the injured segment of the internal carotid artery followed by transarterial (3/6) and/or transvenous (4/6) obliteration of the fistula with detachable platinum coils. In 2 cases, a liquid adhesive was also used. In all instances, a compliant balloon was inflated within the stented arterial segment during coil deposition to avoid extension of coils into the parent artery. RESULTS: All 6 fistulas were obliterated, and each internal carotid artery was successfully reconstructed. Except for posttraumatic cranial nerve dysfunction in 1 patient, clinical outcome was very good. Follow-up angiograms in 3 of the 6 patients obtained at intervals between 3 and 6 months (mean, 4.5 months) revealed no fistula recurrence and no evidence of intimal hyperplasia within the stent. CONCLUSION: In this series of patients with high-flow carotid cavernous fistula associated with severe injury to the internal carotid artery, stent-assisted coil placement offered a safe and effective treatment. Stent-assisted coil placement may increase the ability to successfully treat fistulas with severe injury to the internal carotid artery with preservation of the parent artery.     

经动脉入路血管内治疗142例创伤性颈内动脉海绵窦瘘临床分析

目的 验证经动脉入路血管内治疗对创伤性颈内动脉海绵瘘(CCF)的治疗效果.方法 142例经全脑血管造影确诊为颈内动脉海绵窦瘘,行常规可脱球囊栓塞术,其中7例行球囊栓塞失败,改为全麻下行Jostent覆膜支架成形术.结果 135例患者局麻下成功行可脱球囊栓塞术,7例行球囊栓塞失败后于全麻下成功行Jostent覆膜支架成形...     

带膜支架在血管内治疗外伤性颈动脉海绵窦瘘中的应用

目的 探讨Jostent冠脉带膜支架对于颈动脉海绵窦瘘的血管内治疗效果. 方法 于2001年6月-2007年5月应用Jostent冠脉带膜支架治疗8例外伤性颈动脉海绵窦瘘. 结果 在8例患者中带膜支架被成功放置于靶动脉,导致瘘完全消除并保持载瘘动脉畅通,临床效果满意,无手术相关并发症发生.6例患者于带膜支架放置后6个月获造影随访,显示瘘口未再通,载瘘动脉畅通. 结论 带膜支架对于某些颈动脉海绵窦瘘是有用的血管内治疗手段.带膜支架的制作工艺仍有待发展和优化,以使之适用于脑血管系统.     

颈内动脉的功能解剖及覆膜支架应用的可行性探讨

覆膜支架用于颅段颈内动脉的病变,是医学界一直关注的问题.将冠脉支架加载膜性材料（覆膜支架）后用于颅内段颈动脉血管病变的治疗,近年来,国外已有个案报道.颈内动脉的颅段走行在骨性结构中,迂曲而且发出许多分支动脉,因此,有必要在深入了解颈内动脉功能解剖的基础上,再对覆膜支架在颈内动脉中使用的可行性进行探讨.     

以突眼为表现的眼部血管病——颈动脉海绵窦瘘的介入治疗

目的探讨颈动脉海绵窦瘘眼部表现特点、影像学检查及介入治疗方法。 方法回顾分析5年中18例首诊于我院眼科的颈动脉海绵窦瘘者的眼部症状及体征、影像学检查、治疗方法等。18例患者均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例,应用弹簧圈+Onyx胶封堵瘘口3例,覆膜支架隔绝瘘口3例。 结果所有病例中最常见的眼部表现为搏动性眼球突出、球结膜充血水肿、眼球运动障碍等。头颅或眼部CT平扫检查所有病例均显示患侧眼球突出,眼上静脉增粗;全部患者均行数字减影血管造影检查明确诊断。本组18例（20眼）均行介入手术治疗,其中应用可解脱球囊封堵瘘口12例（14眼）,结果10例（12眼）瘘口完全闭塞,发生并发症2例,无严重并发症或死亡病例。应用弹簧圈+Onyx胶封堵瘘口3例（3眼）、覆膜支架隔绝瘘口3例（3眼）,瘘口均完全闭塞,无并发症或死亡病例。全部手术患者眼部症状和体征均得到明显改善。随访时间（12±3.4）个月,无复发病例,颈动脉覆膜支架内未发生狭窄及闭塞。 结论对于以突眼及其他相关症状就诊于眼科的患者,应考虑颈动脉海绵窦瘘的可能,血管造影是该病诊断的金标准,介入手术治疗对颈动脉海绵窦瘘是安全有效的。     

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.     

Depicting cerebral veins by three-dimensional CT angiography before surgical clipping of aneurysms

BACKGROUND AND PURPOSE: Cerebral veins show wide variation, and unexpected veins occasionally limit surgical procedures for clipping of cerebral aneurysms. This study was undertaken to assess the utility of three-dimensional CT angiography (3D-CTA) in the evaluation of venous anatomy before surgical clipping of cerebral aneurysms. METHODS: 3D-CTA was performed in 19 patients before pterional craniotomy. The venous anatomy visualized by use of 3D-CTA was compared retrospectively with intraoperative findings. RESULTS: 3D-CTA clearly depicted the superficial sylvian veins (SSVs) in 17 of 19 cases. In three of these 17 cases, 3D-CTA failed to reveal the additional connecting veins from SSVs to the midportion of the sphenoid wing. 3D-CTA also depicted bridging veins from: 1) the basal vein of Rosenthal to the sphenoparietal sinus (SPS) (three cases); 2) a junction of the anterior cerebral vein and the deep middle cerebral vein to the SPS (two cases); 3) the anterior cerebral vein into the cavernous sinus (one case); and 4) the deep middle cerebral vein to the cavernous sinus in one case. Surgical findings corresponded well with the angiographic findings. 3D-CTA depicted bridging veins from the frontal base into the SPS in two cases; retraction of the frontal lobe was severely limited in these cases. 3D-CTA also exhibited anatomic variation of deep cerebral veins, which suggests the utility of 3D-CTA in evaluating the risks carried by sacrifice of some bridging veins. In two patients, aneurysmal dissection was restricted because of adhering veins. 3D-CTA depicted these cerebral veins to be lying in contact with the aneurysm. In one case, the contiguous vein was hidden behind a large middle cerebral artery aneurysm; 3D-CTA was helpful for visualization of this vein. CONCLUSION: 3D-CTA can clearly depict the venous anatomy of the brain and is useful for surgical planning of a pterional or temporopolar approach for cerebral aneurysms.     

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.     

Direct caroticocavernous fistula and traumatic dissection of the ipsilateral internal carotid artery: endovascular treatment

After severe craniocerebral trauma a 14-year-old boy developed progressive exophthalmos with venous congestion and chemosis, due to a direct caroticocavernous fistula. Angiography revealed traumatic occlusion of the ipsilateral internal carotid artery and absence of the inferior petrosal sinus. After failure of an approach via the anterior and posterior communicating arteries, the cavernous sinus was successfully catheterised through the occluded internal carotid artery, and embolisation performed with coils. Received: 21 July 1998/Accepted: 5 April 1999     

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。     

Transcatheter Closure of a Chronic Iatrogenic Arteriovenous Fistula Between the Carotid Artery and the Brachiocephalic Vein with an Amplatzer Duct Occluder in Combination with a Carotid Stent

We report an original method of transcatheter closure of an arteriovenous fistula using the combination of an Amplatzer PDA occluder and a carotid stent. The fistula was between the left carotid artery and the brachiocephalic vein. The patient had significant left-to-right shunt and was highly symptomatic. Due to the large orifice and pseudoaneurysmatic enlargement of the fistula, we had to use a large Amplatzer PDA occluder and the protruding part of the PDA device disk had to be covered with a carotid stent. The fistula was completely closed. The patient stopped having symptoms and, 2 years after the procedure, the effect persists.     

Spontaneous resolution of symptoms in an infant with a congenital dural caroticocavernous fistula

We report a 5-week-old boy with a congenital dural caroticocavernous fistula (CCF). He had gradually progressive proptosis, dilated conjunctival veins, chemosis, abducens nerve palsy and an objective bruit. Angiography of the right common carotid artery revealed fistulous communication in the cavernous sinus (CS) region. The CS was fed by the middle meningeal artery and drained through the superior ophthalmic vein and the superior petrosal vein. The child's symptoms and signs disappeared within a few weeks and did not recur over 11 months. At that time, however, angiography still showed a small communication between the right external carotid artery and the CS.     

Intracranial arteriovenous fistula caused by endovascular stent-grafting and dilatation

A 58-year-old man developed a self-occluding arteriovenous fistula following stent-grafting of the right internal carotid artery (ICA). Due to prolonged ischaemic neurological deficits carotid angiography had been performed 3 weeks previously. It revealed marked atherosclerotic lesions predominantly narrowing the distal right carotid siphon. MRI confirmed ischaemic lesions and massive deficits of perfusion in the right ICA cerebral territory. Stent-grafting was performed successfully, but subsequent angiography revealed a new arteriovenous fistula adjacent to the stent, between the right carotid siphon and the cavernous sinus. On angiography 10 days later, the fistula no longer was present, and flow MRI were normal; the patient was by then asymptomatic. Arteriovenous fistula can thus complicate following endovascular stenting.     

Cerebral MR venography

This paper illustrates the technique and clinical use of cerebral MR venography (MRV). Dural sinus thrombosis is detected by both two-dimensional time-of-flight (TOF) and three-dimensional phase-contrast (PC) techniques. Venous angiomas are demonstrated by the three-dimensional PC method. The arterial feeders, nidus and draining veins of cerebral arteriovenous malformation (AVM) can be visualized on contrast-enhanced TOF three-dimensional MR angiogram. The high-flow draining veins of cerebral and dural AVMs, vein of Galen malformation and carotid cavernous fistula are better seen on contrast-enhanced three-dimensional gradient-echo MRV.     

Demonstration of an early draining vein by MR angiography

We present a case of an arteriovenous malformation (AVM) where standard MR angiography demonstrated an enlarged basal vein of Rosenthal. The lenticulostriate branches of the middle cerebral artery were suggested but not conclusively shown, as the feeders of the AVM. Therefore, it could not be determined whether the enlarged vein was part of an AVM or of a venous angioma. By using a saturation pulse inferior to the image volume including the basal vein of Rosenthal and the middle cerebral artery, the transmission of "black blood" to the basal vein of Rosenthal was demonstrated. This implied early venous draining, which confirmed that the lesion represented an AVM.     

颈动脉海绵窦瘘的临床及影像学诊断

目的:分析颈动脉海绵窦瘘的临床及影像学特征。方法:回顾性分析25例具有完整临床资料的颈动脉海绵窦瘘患者的临床、全脑血管造影及10例螺旋CT表现。结果:临床表现为颅内杂音、不同程度的搏动性突眼、眼球运动障碍,视力减退或伴有复视、结膜水肿和充血。CT表现为眼球突出、眼上静脉增粗、海绵窦扩大、密度增高、眼球边缘模糊、眼睑肿胀。全脑血管造影表现为对比剂自颈内动脉或颈外动脉分支溢入海绵窦,形成一团浓密的不规则阴影,海绵窦及眼静脉等早期显影而颈内动脉床突上段和大脑前、中动脉不易充盈,并且可观察到瘘口位置、大小及侧支循环情况。结论:根据颈动脉海绵窦瘘的临床表现和CT征象可以诊断颈动脉海绵窦瘘,脑血管造影是其诊断的金标准,并为进一步选择治疗方案提供依据。     

外伤性颈动脉海绵窦瘘的综合影像评价

目的 评价各种影像学检查手段在诊断外伤性颈内动脉海绵窦瘘中的作用。资料与方法 回顾性分析15例颈动脉海绵窦瘘患者的各种影像学表现，其中CT、超声检查15例，脑血管造影12例，MRI检查3例。结果 颈内动脉海绵窦瘘CT表现为：眼球突出，眼上静脉扩张和海绵窦增大(15／15)，眶内软组织肿胀(9／15)和眼外肌肥厚(10／15)。MRI表现与CT大致相同，MRA可立体显示扩张的眼上静脉和瘘口(2／3)。脑血管造影于动脉期可见患侧海绵窦扩大显影并眼上静脉逆向充盈显影(12／12)，并可见瘘口显示(11／12)，压迫患侧颈总动脉，健侧颈内动脉造影可见患侧颈内动脉和海绵窦显影(9／12)。经颅多普勒超声检查可显示眼上静脉和海绵窦区的异常血流信号(15／15)，并能准确评价颈内动脉各段血流动力学改变。结论 各种影像学检查手段都有其优势和局限性，各种手段综合应用才能满足临床需要。     

Traumatic arteriovenous fistula treated by superselective embolisation with microcoils: case report

A 27-year-old man with a traumatic direct dural arteriovenous fistula (DAVF) was treated using embolisation microcoils. He had suffered blunt trauma to the head while drunk and was aware of no neurological deficit. A few days after the accident, however, he noticed a bruit in the right temple. Angiography demonstrated a direct DAVF fed by the right middle meningeal artery and draining into a right temporal dural vein and the ipsilateral cavernous sinus. A Tracker-18 catheter was passed without difficulty through the fistula and the draining vein was then embolised from distal to proximal with microcoils, and finally the fistula was occluded with microcoils, resulting in total obliteration of the fistula. Immediately after the embolisation, the patient could no longer hear the bruit. Thus, when a microcatheter can be introduced into the draining vein, microcoils can be used as emboli in the treatment of direct DAVF.     

Treatment of a direct carotid-cavernous fistula in a patient with type IV Ehlers-Danlos syndrome: a novel approach

We report a case of a 34-year-old female with type IV Ehlers-Danlos syndrome diagnosed with a carotid cavernous fistula presenting with progressive proptosis. Endovascular embolization using balloons or coils carries a high risk of complications in this group of patients, owing to the extreme fragility of the blood vessels. Initial treatment was conservative until an intracerebral haemorrhage occurred. To avoid transfemoral angiography, the ipsilateral carotid arteries and the internal jugular vein were surgically exposed for insertion of two endovascular sheaths. The patient was transferred from theatre to the angiography suite and the sheaths were used for embolization access. The fistula was closed, with preservation of the carotid artery, using Guglielmi detachable coils deployed in the cavernous sinus from the arterial and venous sides. Rapid resolution of symptoms and signs followed, which was sustained at 6-month follow-up. This technique offers alternative access for endovascular treatment, which may reduce the high incidence of mortality associated with catheter angiography in this condition.