颈动脉海绵窦瘘的血管内介入治疗

目的 探讨不同类型颈动脉海绵窦瘘(carotid cavernous fistulas, CCF)的介入治疗方法及疗效.方法 回顾性分析以眼部症状在眼科首诊、经介入治疗的17例CCF患者临床资料,全部经DSA进一步确诊和治疗.其中15例有明确外伤史,2例为自发性CCF.1例双侧病变,经动脉途径以可脱球囊进行栓塞,行颈内动脉闭塞者2例(2/17),部分病例经颈外动脉、经岩下窦或眼静脉以微弹簧圈填塞海绵窦.结果 单纯以可脱球囊栓塞瘘口、保持颈内动脉通畅者13例;闭塞颈内动脉者2例;1例为硬脑膜动静脉瘘(海绵窦型),行眼静脉切开暴露,经眼静脉途径填塞弹簧圈栓塞瘘口;1例经岩上窦栓塞瘘口.所有患者术后症状消失,无脑缺血、异位栓塞等并发症.结论 可脱球囊栓塞是治疗CCF最有效的方法,但存在一定的复发率和颈内动脉闭塞率.配合微弹簧圈可提高复杂CCF的治愈率.     

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。     

应用水膨胀式微弹簧圈栓塞治疗外伤性颈动脉海绵窦瘘

目的总结水膨胀式微弹簧圈（HydroCoil）栓塞治疗颈动脉海绵窦瘘（CCF）的初步体会，对HydroCoil治疗CCF的有效性作出评价。方法选取我院2006年1月以来应用HydroCoil栓塞系统治疗14例外伤性颈动脉海绵窦瘘（CCF）病人，男9例，女5例，平均26．5岁。脑血管造影显示6例瘘口位于右侧颈内动脉海绵窦段，8例位于左侧颈内动脉海绵窦段。结果14例病人CCF术后均不再显影，患侧颈内动脉通畅，所有病人术前的颅内杂音、突眼和球结膜充血等症状在1周内恢复正常，视力也有不同程度的恢复。8例病人术后获得1—3个月脑血管造影随访，CCF均未见复发。没有神经系统并发症发生。结论血管内介入治疗已经广泛应用于颈动脉海绵窦瘘，可脱球囊栓塞仍为首选方法。当病人不能耐受或不允许闭塞患侧颈内动脉时，可以选用HydroCoil。HydroCoil治疗CCF安全、有效、稳定，颈动脉保持通畅率高，长期临床效果仍有待于进一步研究。     

可脱性球囊血管内栓塞治疗外伤性颈内动脉海绵窦瘘临床分析

目的探讨可脱性球囊栓塞治疗外伤性颈内动脉海绵窦瘘的临床意义。方法应用可脱性球囊经动脉途径栓塞治疗12例颈内动脉海绵窦瘘。结果 1次栓塞成功9例,2次栓塞成功3例。结论可脱性球囊栓塞治疗是目前治疗外伤性颈内动脉海绵窦瘘的最好方法。     

动脉瘤性颈内动脉海绵窦瘘的血管内治疗

目的总结应用血管内技术治疗颈内动脉海绵窦段动脉瘤破裂导致颈内动脉海绵窦瘘(CCF)的经验体会。方法回顾性分析8例颈内动脉海绵窦段动脉瘤破裂致CCF患者的临床资料以及应用的血管内技术,其中单纯应用可脱球囊治疗1例,弹簧圈结合可脱球囊进行治疗2例,球囊辅助弹簧圈栓塞治疗2例,覆膜支架治疗1例。结果8例患者中6例治疗成功,无技术相关性并发症;1例治疗前突然死亡;1例放弃治疗。结论血管内技术是治疗颈内动脉海绵窦段动脉瘤破裂致CCF的安全、有效方法。     

颈内动脉闭塞治疗外伤性A+C型颈动脉海绵窦瘘一例

患者男,42岁.因"头部外伤后1个月,右侧搏动性突眼及颅内杂音20 d"入院.入院时查体见右侧眼球突出,球结膜充血水肿,于右侧额颞部听诊可闻及与脉搏一致的杂音.术前行Mata(s)试验1周,患者能够完全耐受闭塞右侧颈内动脉.全脑血管造影显示为右侧颈动脉海绵窦瘘(CCF),经右侧眼上静脉引流.同时发现右侧脑膜中动脉分支与海绵窦沟通,参与瘘的形成,亦向右侧眼上静脉引流.我们尝试用可脱性球囊封堵CCF颈内动脉瘘口.由于瘘口较大,无法单纯用一枚球囊进行封堵.最终使用了4枚球囊,封堵了CCF瘘口的同时,也闭塞了右侧颈内动脉(ICA).经左侧颈内动脉及椎动脉造影,见侧枝循环代偿良好.右侧颈外动脉造影见右侧脑膜中动脉分支与海绵窦的沟通依然存在.术后患者临床症状完全消失.未再给予特殊治疗.45 d后复查发现右侧颈内动脉闭塞完全,颈内动脉瘘口无复发,同时右侧脑膜中动脉分支与海绵窦的沟通完全消失.患者的CCF彻底治愈,无任何临床症状及体征.     

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。     

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。     

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；     

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。     

外伤性颈内动脉假性动脉瘤的介入栓塞治疗(附2例报告)

目的探讨在数字减影血管造影（DSA）透视下用介入栓塞的方法治疗外伤性颈内动脉假性动脉瘤。方法对2例颅脑外伤合并严重鼻出血的患者进行DSA造影,证实有外伤性颈内动脉假性动脉瘤,并且经脑动脉环侧枝功能检测显示功能良好,均给予介入栓塞治疗。结果 2例患者假性动脉瘤栓塞完全,栓塞术后脑血管造影显示脑动脉环侧枝功能良好,无任何并发症和后遗症。结论DSA透视下介入栓塞治疗是治疗外伤性颈内动脉假性动脉瘤首选方法。     

血管内栓塞:治疗颈动脉-海绵窦瘘的最佳方案

本文报告42例颈动脉-海绵窦瘘治疗方法。其中外伤性34例,自发性8例,前者均行可脱性球囊、微弹簧圈等血管内栓塞治疗,颈内动脉通畅率为86％,血管杂音、球结合膜水肿、充血、突眼完全消失。自发性颈内动脉-海绵窦瘘可用保守疗法,但较重的或保守治疗失败者,常需血管内栓塞治疗,但似应以微粒栓塞法为主。本文对各种疗法作了评价及讨论。     

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.     

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。     

Usefulness of ultrasonography in a case of spontaneous carotid-cavernous fistula: a case report]

Since spontaneous carotid-cavernous fistula (CCF) is a dural arterio-venous fistula at the cavernous sinus, which is different from traumatic CCF and CCF associated with a ruptured aneurysm at the cavernous internal carotid artery, cerebral angiography is required in order to differentiate these condition. We here report a case of spontaneous CCF, in which a result of ultrasonographic evaluation of cervical arteries well corresponded with that of cerebral angiography. Ultrasonography showed increased blood flow and decreased pulsatility index in the ipsilateral external carotid artery, contralateral internal and external arteries, and these values in all arteries resolved within normal range after the interventional embolization. Ultrasonography is less invasive examination and can be easily performed even in outpatients for observation of spontaneous CCF.     

创伤性颈动脉海绵窦瘘的可脱性球囊栓塞治疗技术

目的探讨创伤性颈动脉海绵窦瘘的临床表现和血管内介入栓塞治疗效果。方法回顾性分析本组共32例创伤性颈动脉海绵窦瘘的临床表现,采用可脱性球囊微导管技术经股动脉途径闭塞颈内动脉破口处或破口处患侧颈内动脉主干。结果28例一次性治愈;4例术后16~48h因球囊发生早泄移位复发,经再次以可脱性球囊栓塞后治愈。本组有28例(87.5%)闭塞了瘘口,颈内动脉主干保持通畅;4例同时闭塞了瘘口及颈内动脉主干。27例获随访(术后6个月~5.2年),无复发。结论采用可脱性球囊栓塞技术是治疗创伤性颈动脉海绵窦瘘的首选方法。     

Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery

A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.     

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。     

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.