MRI diagnosis of cavernous sinus invasion by pituitary adenomas

Several MRI signs are helpful for the preoperative MRI diagnosis of cavernous sinus invasion by an adenoma. The first step is to analyse the percentage of encasement of the intracavernous ICA by the adenoma. If this percentage is greater than or equal to 66%, the cavernous sinus is invaded. If the percentage of encasement of intracavernous CA is less than 25%, the cavernous sinus is not invaded. If the percentage of encasement is between 25 and 66%, the analysis of the cavernous venous compartment, the drawing of intercarotid lines and the analysis of the shape and venous compartments of the cavernous sinus are necessary. The cavernous sinus invasion remains very likely if the carotid sulcus venous compartment is obliterated, or if the lateral intercarotid line is crossed. Conversely, if the median intercarotid line is uncrossed, the superior venous compartment is visible, the cavernous sinus is of normal size, or there is no bulging of its lateral dural wall, invasion of the cavernous sinus space can reliably be excluded.     

经未显影静脉窦栓塞治疗硬脑膜动静脉瘘

目的探讨经未显影静脉窦栓塞治疗硬脑膜动静脉瘘（DAVF）的可行性、安全性及有效性。方法回顾性分析92例经未显影静脉窦栓塞治疗的DAVF患者的临床资料，其中病变位于海绵窦区91例，侧窦区1例。经颈内静脉的起始段探查未显影岩下窦，进入引流静脉窦内栓塞海绵窦区DAVF；通过颈内静脉探查未显影乙状窦，进入静脉窦栓塞侧窦区DAVF。首选可控纤毛弹簧圈进行栓塞，待血流减慢以后，用游离纤毛弹簧圈继续栓塞。若仍存在少量瘘口，通过静脉窦内注射液体栓塞剂（25％～33％Glubran或Onyx18），观察置管的成功率、安全性和栓塞的疗效。术后6个月通过电话、门诊或DSA随访。结果92例患者中，均未出现并发症，无死亡病例。1例海绵窦区DAVF患者置管失败；其余91例患者均顺利置管，并成功进行静脉栓塞。所有患者栓塞后即刻造影，均未见异常静脉窦早显，瘘口消失，达到了影像学上治愈。置管成功率及治愈率均为99％（91／92）。术后6个月对38例进行随访，无一例DAVF复发。对其余患者进行电话或门诊随访。所有患者临床症状好转或消失。结论经未显影静脉窦栓塞治疗DAVF，尤其对于海绵窦区DAVF，经未显影岩下窦超选择置管进行栓塞，具有较高的可行性、安全性及有效性，可作为海绵窦区DAVF的首选常规治疗方法。     

经面静脉入路栓塞治疗海绵窦区硬脑膜动静脉瘘

目的探讨经面静脉途径治疗海绵窦区硬脑膜动静脉瘘（arteriovenous fistula，AVF）的方法和疗效。方法回顾性分析经面静脉途径（导管置入股静脉-面静脉-角静脉-眼上静脉-海绵窦）治疗7例海绵窦区硬脑膜AVF的病例资料，其中5例患者岩下窦闭塞；1例患者岩下窦开放，但其AVF所在的海绵窦和岩下窦之间无交通；1例患者的瘘与岩下窦相通。对该患者先行经岩下窦栓塞海绵窦后部，然后再经面静脉途径栓塞海绵窦前部。其他6例患者只经面静脉途径行栓塞治疗。结果血管造影显示，7例患者的角静脉和眼上静脉的走行清晰，其中有1例眼上静脉闭塞的患者，由于导管无法置入闭塞的眼上静脉，导致经静脉途径治疗终止。其余6例患者经面静脉入路用弹簧圈栓塞海绵窦治疗后，4例达到完全栓塞，2例临床症状明显好转。结论相对其他静脉途径而言，经股静脉-面静脉入路是血管内治疗海绵窦区硬脑膜AVF的一种很有价值的方法，即使该入路对术者手术技能要求较高，但仍然不失为一种安全和有效的血管内治疗方法。     

Venous infarction secondary to septic cavernous sinus thrombosis

A 65-year-old woman with poorly controlled diabetes presented bilateral miosis, bilateral abducens nerve palsy, and left hemiparesis. On MRI, cavernous sinus thrombosis, subdural empyema and hemorrhagic infarction in the frontotemporal lobe were detected. Cerebral angiogram revealed filling defect in the cavernous sinus with venous congestion but no involvement of internal carotid artery. Postmortem examination demonstrated hemorrhagic infarction in the right frontotemporal lobe as well as hemorrhagic necrosis of the pituitary gland. It should be noted that venous congestion due to cavernous sinus thrombosis may cause these complications.     

静脉窦内球囊保护下Onyx栓塞侧窦区硬脑膜动静脉瘘的随访分析

目的初步探讨侧窦区硬脑膜动静脉瘘的栓塞治疗中,静脉窦内球囊保护技术的疗效及安全性。方法回顾性连续纳入2012年12月至2016年8月,经静脉窦内球囊保护下,使用Onyx栓塞侧窦区硬脑膜动静脉瘘7例患者,并对其临床资料、影像学资料及随访结果进行分析。结果 7例患者中,瘘口位于乙状窦区3例、横窦区4例。术后即刻造影显示完全栓塞5例,大部分栓塞2例,球囊保护静脉窦均保持通畅。临床随访7例,随访时间为术后6~43个月,无新发神经功能缺损。7例患者均获全脑DSA复查,随访时间为术后6~11个月,提示5例完全治愈,其中4例静脉窦通畅,1例闭塞;1例瘘口稳定且静脉窦通畅,1例瘘口新发合并静脉窦闭塞。结论静脉窦内球囊保护下栓塞硬脑膜动静脉瘘在栓塞瘘口的同时,可长期维持静脉窦通畅,有利于维持栓塞效果的稳定性。     

Carotid cavernous fistula in a patient with Graves' ophthalmopathy

The clinical manifestations of carotid cavernous fistula, an abnormal arteriovenous connection between the cavernous sinus and the carotid artery, can closely mimic the cardinal signs of Graves' ophthalmopathy, an inflammatory disorder of the orbit usually associated with autoimmune thyroid disease. Therefore, carotid cavernous fistulas are generally considered in the differential diagnosis of Graves' ophthalmopathy, especially when the eye involvement is unilateral or asymmetric, and there is the need for exclusion of rarer etiologies of orbital disease. This is the first report of the simultaneous occurrence of Graves' ophthalmopathy and carotid cavernous fistula. The patient was a 67-yr-old woman who presented with a history of Graves' disease with mild bilateral ophthalmopathy treated with radioiodine following a 10-yr therapy with methimazole; after radioiodine treatment, ophthalmopathy deteriorated. At the time of our initial clinical evaluation the ocular involvement of the patient was symmetric, and no evidence of any associated condition was found. However, the response of eye disease to corticosteroid treatment was markedly unequal, resulting in evident asymmetry. This prompted a reconsideration of the diagnosis and a new evaluation of the patient with sensitive techniques, leading to the further diagnosis of carotid cavernous fistula.     

经静脉入路采用Onyx或联合弹簧圈治疗海绵窦区硬脑膜动静脉瘘的疗效

目的探讨经静脉入路采用Onyx或联合可脱性弹簧圈栓塞治疗海绵窦区硬脑膜动静脉瘘的安全性和有效性。方法回顾性分析2007年2月—2010年12月,经静脉入路栓塞治疗的12例海绵窦区硬脑膜动静脉瘘患者的临床资料,其中经岩下窦入路10例,经面静脉-眼上静脉入路2例。单独应用Onyx 8例,Onyx联合可脱性弹簧圈4例。结果①治疗后即刻血管造影显示完全闭塞10例,少量残留2例。单独应用Onyx栓塞治愈6例,好转2例,Onyx联合可脱性弹簧圈栓塞治愈2例,好转2例;总有效率100%,治愈率66.7%,无加重或死亡病例。②2例术中出现心动过缓,3例术后出现眶部疼痛。③对所有患者进行临床随访,随访时间为6～32个月,无复发及加重者。结论静脉入路Onyx或联合可脱性弹簧圈栓塞海绵窦区硬脑膜动静脉瘘的疗效确实,安全可靠。     

磁共振成像诊断海绵窦侵袭型垂体瘤(附39例报告)

目的 建立一套海绵窦侵袭型垂体瘤的MRI诊断系统。方法选取确诊的39例海绵窦侵袭型垂体瘤与同期收治的162例非侵袭型垂体瘤进行对照,分析冠状位MRI图像上肿瘤与海绵窦的关系,包括海绵窦形态的改变、窦内间隙的改变,以及肿瘤与颈内动脉海绵窦段的关系等,将相关的各个类型作为拟诊标准,计算各自的灵敏度(Se)、特异度(Sp)、阳性预告值(PV+)、阴性预告值(PV-)。结果肿瘤包绕颈内动脉≥70％确诊侵袭的意义最大(PV+为100％),肿瘤超过颈内动脉外侧连线的诊断意义也较高(PV+为86.1％);如果肿瘤包绕颈内动脉<20％、肿瘤未超过颈内动脉内侧连线及海绵窦内侧间隙未出现肿瘤,则可排除海绵窦侵袭的存在。结论 系统分析垂体瘤MRI图像的表现,能较准确地诊断海绵窦侵袭型垂体瘤。     

球囊辅助弹簧圈联合Onxy胶治疗颈内动脉海绵窦瘘的疗效分析

目的探讨球囊辅助弹簧圈联合Onxy胶治疗颈内动脉海绵窦瘘（CCF）的安全性及有效性。 方法四川省医学科学院·四川省人民医院神经外科自2018年1月至2020年6月共收治CCF患者19例,均采用球囊辅助弹簧圈联合Onxy胶介入治疗。其中11例岩下窦开放者行经岩下窦静脉途径栓塞治疗,另8例行经颈内动脉瘘口动脉途径栓塞。 结果19例患者栓塞后即刻造影显示海绵窦瘘口完全封闭。术后常规复查头颅CT,未见栓塞剂异位栓塞表现,无新发神经功能障碍表现。所有患者于术后即刻眼静脉症状及颅鸣耳鸣症状均有明显缓解,1~2周内逐步消失。而存在颅神经麻痹症状患者,眼外肌麻痹症状缓解则相对缓慢。 结论通过三维成像后处理剪辑技术,可精准判断瘘口位置;无论经动脉或静脉入路,封堵球囊可精准封闭瘘口,在栓塞过程中使弹簧圈及Onxy胶尽可能接近瘘口附近,从而减少费用,同时提高CCF治疗的安全性及有效性,减少并发症。     

Using two-holed needles for both arterial and venous accesses to the arteriovenous fistula to improve flow during hemodialysis

This prospective study compared methods using both arterial and venous needles with back eyes with those using only arterial needle with back eye for arteriovenous fistula cannulation. Sixty-one patients receiving hemodialysis (HD) via an arteriovenous fistula were evaluated. All patients underwent arteriovenous fistula puncture using only arterial needle with back eye in first 3 months and both arterial and venous needles with back eyes in following 3 months. Arterial and venous pressures, blood flow velocities, total blood volume cleared, and Kt/V values were compared. Mean blood flow velocity, arterial pressure, Kt/V, and cleared total blood volume values were higher and venous pressure was lower in patients who underwent cannulation using both needles with back eyes than in those with only the arterial needle with back eye. For arteriovenous fistula cannulation, using both arterial and venous needles with back eyes provides adequate HD more successfully.     

Patency and venous pressure of arteriovenous fistulas for hemodialysis

The early patency of arteriovenous fistulas created for hemodialysis is affected by various factors, including venous stenosis. We conducted a study to investigate the effect of venous stenosis on early patency by examining perioperative arterial and venous pressures of the fistula. Among the 15 patients selected for the study, 11 had snuff-box fistulas, 3 Brescia-Cimino, and 1 brachial. A thrill was palpable over the anastomosis in 10 patients and absent in 5 patients. In terms of venous pressure, the patients with a thrill had a mean systolic pressure of 35.8 mm Hg and systolic-diastolic pressure gradient of 3.4 mm Hg. In the patients without a thrill, the values were 102.6 mm Hg and 42.8 mm Hg, respectively. In conclusion, patients with venous obstruction in the fistula had a much higher venous pressure than those with a patent fistula. If venous stenosis is suspected, measurement of fistula pressures may be useful for determining the early patency of arteriovenous fistulas.     

静脉窦内球囊辅助Onyx18闭塞上矢状窦及侧窦治疗硬脑膜动静脉瘘

目的探讨静脉窦内球囊辅助栓塞剂——Onyx18闭塞上矢状窦及侧窦（横窦和乙状窦）治疗硬脑膜动静脉瘘（DAVF）的可行性、安全性和有效性。方法回顾性分析2008年2月—2012年6月,经静脉途径在静脉窦内使用保护球囊,经动脉和（或）静脉途径,采用Onyx18栓塞治疗上矢状窦区和侧窦区DAVF的24例患者的临床资料,分析球囊辅助栓塞的效果以及并发症的发生情况。结果①本组24例患者,病变位于上矢状窦区5例,侧窦区19例。对上矢状窦区病变和侧窦区病变使用Hyperform 7 mm×7 mm球囊各1例,对其余患者使用外周血管扩张用球囊。②对上矢状窦区病变的患者经动脉栓塞3例,经静脉栓塞2例,使用球囊均基本闭塞静脉窦;对侧窦区病变患者经动脉栓塞10例,经静脉栓塞7例,动静脉联合栓塞2例;使用球囊基本闭塞静脉窦8例,部分闭塞静脉窦11例。③上矢状窦病变患者3例栓塞后治愈,有2例随访半年无复发,1例栓塞后少量残余,1年后复查造影无明显变化;在侧窦区病变的患者中,对1例患者行两次栓塞后瘘口消失,其余患者均经1次栓塞治愈,对其中7例患者治疗后半年进行了血管造影随访,未见复发。结论对经严格选择适应证的DAVF患者在球囊辅助下使用Onyx18闭塞侧窦（横窦和乙状窦）和上矢状窦,治疗DAVF是一种相对安全、有效的方法,能最大程度地保留静脉窦的通畅性。     

Can the pituitary secrete directly to the brain? (Affirmative anatomical evidence).

Vascular casts of 10 rhesus monkey pituitary glands and three vascular casts of the rhesus monkey cavernous sinus were examined by scanning electron microscopy. A continuous neurohypophyseal capillary bed was found uniting the infundibulum, infundibular stem, and infundibular process. The neurophypophysis was supplied by three groups of arteries: superior hypophyseal, middle hypophyseal, and inferior hypophyseal. Numerous anastomoses were found between individual arteries, and some hypophyseal arteries formed anastomotic links between different portions of the circle of Willis. Veins located at the caudal pole of the infundibular process, capillaries linking the infundibulum to the hypothalamus, and portal vessels extending from the infundibulum to the adenohypophysis provided efferent vascular pathways from the neurohypophysis. The adenohypophysis received no direct arterial supply; its entire afferent vascular supply was provided by portal vessels. Lateral hypophyseal veins were not found; small adenohypophyseal veins joined larger neurohypophyseal veins to form confluent pituitary veins which extended to the cavernous sinus. The capacity of the venous connections draining the adenohypophysis directly to the cavernous sinus appeared small when compared to that of of the long portal vessels supplying the adenohypophysis. However, many of the short portal vessels interposed between the adenohypophysis and the infundibular stem and process were well arranged to function as alternative efferent routes from the adenohypophysis. The limited potential for venous drainage directly to the cavernous sinus suggests that blood leaves the adenohypophysis by other routes; blood carried via long portal vessels from the infundibulum to the adenohypophysis may return to the neurohypophyseal capillary bed via short portal vessels. This anatomical study suggests that hypothalamic and adenohypophyseal secretions are conveyed to the capillary bed of the neurohypohysis. These secretions may leave the neurohypophysis via any of seven potential routes: one efferent route is directed to the adenohypophysis, another route is directed to the systemic circulation, but five of the potential efferent routes are directed toward the brain.     

Percutaneous intervention for restoration of patency of occluded lower limb arteriovenous dialysis access

BackgroundArteriovenous (AV) fistula thrombosis is a serious complication in patients undergoing hemodialysis, often presenting with symptoms of venous hypertension, failure to dialysis and uremic symptoms. Treatment is aimed to provide symptomatic relief and to maintain hemodialysis access site patency.AimTo describe our initial experience in the endovascular treatment of lower limb AV dialysis access (AV fistula) thrombosis and/or obstruction in patients undergoing hemodialysis.Settings and designThis was a retrospective study carried out in a tertiary care center. Study duration was 24 months. Follow-up was variable.Materials and methodsTwo patients with chronic kidney disease with stage 5 renal failure undergoing hemodialysis presented with lower limb arteriovenous dialysis access (arteriovenous fistula) failure between July 2014 and September 2016. Both the patients underwent endovascular treatment and were analyzed retrospectively.Results and conclusionBoth the patient underwent successful endovascular treatment for the failure of the lower limb AV dialysis access thrombosis and/or obstruction. One patient had minimal dye extravasation during manipulation of the guide wire, which ceased spontaneously. On follow-up, both patients maintained patency of the dialysis access and are undergoing successful hemodialysis. One patient had a recurrence of the thrombosis of the fistula at 9^th month of the follow-up. Endovascular treatment was tried but we could not succeed. However, we found endovascular treatment safe and effective in treating AV fistula failures.     

大鼠静脉窦高压后硬脑膜微循环变化的动态观察

目的观察大鼠静脉窦高压后硬脑膜微循环的变化，探讨硬脑膜动静脉瘘发生的机制。方法将110只大鼠随机分成两组：实验组85只，对照组25只。实验组大鼠闭塞其上矢状窦和左侧横窦，同时行右侧颈总动脉和颈外静脉吻合，造成静脉窦高压。然后分别在术后7、14、21、28、40、60、90d取实验组大鼠3只和对照组大鼠1只观察硬脑膜微循环，并计量上矢状窦旁开1mm，分别与上矢状窦平行和垂直的1mm直线上所能观察到的直径≤10μm的血管数目和直径的变化。结果在静脉窦高压7d，大鼠硬脑膜未见血管增生；14d后硬脑膜才出现血管增生。90d后，实验组和对照组血管数目差异无显著性（P〉0．05）。实验组大鼠硬脑膜中可观察到毛细血管网中动静脉直接通道的开放，血液经该通道进入静脉的路径直而短（21d）。第28天时实验组大鼠可观察到动静脉瘘形成，而且其形态和结构与正常动静脉短路类似，但连接的血管增粗，不再是毛细血管。结论静脉窦高压形成初期，硬脑膜血管增生活跃，后期血管增生减弱或消失。从瘘口的位置和结构分析，瘘口很可能是由原来存在的血管薄弱部位逐渐演化而来。     

Septic cavernous sinus thrombosis after minor head trauma: A case report

Rationale:Septic cavernous sinus thrombosis (SCST) is a rare but life-threatening condition that commonly arises from infections, including paranasal sinusitis, otitis media, and skin infection. Meanwhile, head trauma as a predisposing factor of SCST has been scarcely reported. We report a case of SCST complicated by meningitis after minor head trauma, even in the absence of identifiable fractures.Patient concerns and diagnosis:A 77-year-old female presented with diplopia combined with ocular pain and headache lasting a week. She had a recent blunt head trauma 2 weeks before the diplopia onset. The trauma was not accompanied by identifiable skull fractures, bleeding, or loss of consciousness. Neurological examination revealed incomplete ptosis, eyelid swelling, and medial and vertical gaze limitations of both eyes. Gadolinium-enhanced brain magnetic resonance imaging demonstrated multifocal thrombotic filling defects, including those of the cavernous sinus, sinusitis involving the sphenoid and ethmoid sinuses, and otomastoiditis. The cerebrospinal fluid assay result was compatible with bacterial meningitis. A tentative diagnosis of SCST complicated by bacterial meningitis and multifocal cerebral venous thrombosis was made based on clinical, laboratory, and neuroradiologic findings.Intervention:Intravenous triple antibiotic therapy (vancomycin, ceftriaxone, and ampicillin) for 2 weeks combined with methylprednisolone (1 g/d for 5 days) was administered. Despite the initial treatment, carotid-cavernous fistula was newly developed during hospitalization. Therefore, coil embolization was performed successfully for the treatment of carotid-cavernous fistula.Outcomes:The symptoms of the patient including diplopia gradually improved during the 8-month follow-up period.Lessons:Minor head trauma is a rare but possible cause of SCST. Early recognition and prompt treatment are essential for improving outcomes. Moreover, close observation is warranted, even if apparent serious complications were absent during initial evaluations in minor head trauma.     

老年人常见透析血管通路及其运用

随着尿毒症患者的逐年增多,血液透析已经成为肾衰竭患者的重要选择之一,建立并维护稳定可靠的血管通路成为透析顺利进行的重要前提。由于高并发症率、预期寿命的缩短和生存质量的下降等各种因素的影响,使得老年尿毒症患者透析血管通路的建立和选择较青年人更为复杂,本文着眼老年人血管的特点及中心静脉留置导管、自体动静脉内瘘及移植血管搭桥瘘几类血管通路在老年人和青年人中使用的差异性,对老年人透析血管通路的选择进行分析讨论。     

闭塞静脉窦治疗颅后窝硬脑膜动静脉瘘的疗效分析

目的探讨经静脉途径闭塞静脉窦治疗颅后窝硬脑膜动静脉瘘（DAVF）的治疗方法及疗效。方法对经全脑血管造影确诊的颅后窝DAVF的10例患者,先采用经动脉栓塞,而后对其中的4例行开颅直视下填塞静脉窦,对6例患者经静脉内弹簧圈填塞瘘口集中的横窦和乙状窦。结果①对10例患者技术操作均获成功,并于术后均行全脑血管造影复查,显示6例瘘口全部消失,4例瘘口消失〉80％,残余瘘口无明显向皮质静脉引流的趋势。②所有患者术后颅内杂音消失。4例开颅直视下填塞静脉窦的患者,在术后10d造影复查未见复发,门诊或电话随访2～24个月,亦未见复发;6例经静脉途径弹簧圈闭塞静脉窦患者中,1例在术后第6个月DAVF复发,表现为搏动性杂音,再次给予动脉栓塞后症状减轻。5例表现为视力下降,其中3例在术后6—12个月内视力有不同程度的恢复,2例患者的视力术后恢复不明显。7例视盘水肿的患者5例有恢复。3例术前患者脑脊液压力〉300mmH2O的患者,术后分别降至240、230、200mmH2O。结论颅后窝DAVF病情复杂,单纯动脉栓塞难以达到良好疗效;无论直视下填塞或经静脉途径闭塞患侧脑静脉窦,对复杂颅后窝DAVF均有肯定的疗效     

Anterior jugular-internal jugular bypass to salvage a dialysis arteriovenous fistula

Thrombosis of the anonymous vein can compromise the arteriovenous fistula in chronic renal patients on hemodialysis. Clinical manifestations include edema of the arm, stasis acrocyanosis, tugor of the neck and shoulder veins, and severe headache. The fistula may have to be closed to achieve symptom relief, requiring a catheter for dialysis until an new arteriovenous fistula becomes functional. In case of stenosis or occlusion of the brachiocephalic venous axis, the goal is to preserve a functional fistula yet resolve symptoms. Self-expanding stents have been used but results have been less than satisfactory or short-lived. Different surgical bypass techniques have been proposed. We report an anterior jugular-internal jugular bypass used to salvage a dialysis arteriovenous fistula.     

Balloon embolization of latrogenic aortocoronary arteriovenous fistula

A detachable latex balloon was used to occlude an iatrogenic aortocoronary arterio-venous fistula. The aim of providing retrograde myocardial perfusion was not achieved to any significant degree because of rapid recruitment of collateral venous routes to the coronary sinus. This may have implications for the effectiveness of deliberate grafting of the coronary venous system with proximal venous ligation, as has been recommended when the coronary arterial system is small and diffusely diseased.