硬脊膜动静脉瘘治疗预后相关因素分析——一种新的手术预后评分系统

目的硬脊膜动静脉瘘(Spinal dural arteriovenous fistulas,SDAVFs)患者预后因素分析。方法通过对中国医科大学附属第一医院2012年1月至2017年12月间收治的41例SDAVFs患者的流行病学特征、影像学特点、治疗方法及随访结果等资料进行回顾性分析。分为手术治疗组30例(SDAVFs切断术,不包括SDAVFs栓塞术)及非手术治疗组11例(拒绝手术,选择药物或物理治疗者),运用Aminoff and Logue评分(Aminoff and Logue Score,ALS)量化脊髓功能情况,分析SDAVFs患者治疗预后的相关因素。结果手术治疗组影像学治愈率100%,临床症状改善率36.7%(11/30),症状无变化者63.3%(19/30),临床症状加重者0%(0/30);非手术治疗组,临床症状改善率0%(0/11),症状无变化者27.3%(3/11),临床症状加重者72.7%(8/11);手术治疗能够明显改善SDAVFs患者功能预后(P=0.017);而患者治疗时年龄(P=0.020)、患病时间(P=0.037)、迂曲扩张的引流静脉长度(P=0.020)及患病当时临床症状严重程度(P=0.035)与患者手术预后有统计学意义,并提出全新的SDAVFs手术预后评分系统,7～8分为术后临床症状改善率高,而4～6分为术后临床症状改善不明显(P=0.000)。结论 SDAVFs切断术影像学治愈率极高,且相对于非手术治疗组的临床症状改善率亦较明显;根据相关预后因素(年龄、患病时间、迂曲扩张的引流静脉长度及患病当时的临床症状严重程度)提出的硬脊膜动静脉瘘手术预后评分系统,可用来评估预后。     

应用复合手术平台治疗硬脊膜动静脉瘘

目的探讨复合手术平台在硬脊膜动静脉瘘(SDAVF)治疗中的应用价值。方法回顾性分析2018年1月至2019年10月复合手术治疗的18例SDAVF的临床资料。结果 18例手术时间3.1～4.6 h,平均(3.5±0.8)h。术后即刻造影未发现瘘口及异常引流静脉。无手术死亡病例,未发生与造影相关并发症。术后3个月复查脊髓造影均无复发,18例症状均明显改善;术后1年,造影复查未发现复发。结论利用复合手术平台治疗SDAVF,定位准确,手术损伤小,复发率低,疗效好。     

硬脊膜动静脉瘘治疗预后相关因素分析——一种新的手术预后评分系统

目的 硬脊膜动静脉瘘（Spinal dural arteriovenous fistulas，SDAVFs）患者预后因素分析。方法 通过对中国医科大学附属第一医院2012年1月至2017年12月间收治的41例SDAVFs患者的流行病学特征、影像学特点、治疗方法及随访结果等资料进行回顾性分析。分为手术治疗组30例（SDAVFs切断术，不包括SDAVFs栓塞术）及非手术治疗组11例（拒绝手术，选择药物或物理治疗者），运用Aminoff and Logue评分（Aminoff and Logue Score，ALS）量化脊髓功能情况，分析SDAVFs患者治疗预后的相关因素。结果 手术治疗组影像学治愈率100%，临床症状改善率36.7%（11/30），症状无变化者63.3%（19/30），临床症状加重者0%（0/30）；非手术治疗组，临床症状改善率0%（0/11），症状无变化者27.3%（3/11），临床症状加重者72.7%（8/11）；手术治疗能够明显改善SDAVFs患者功能预后（P=0.017）；而患者治疗时年龄（P=0.020）、患病时间（P=0.037）、迂曲扩张的引流静脉长度（P=0.020）及患病当时临床症状严重程度（P=0.035）与患者手术预后有统计学意义，并提出全新的SDAVFs手术预后评分系统，7~8分为术后临床症状改善率高，而4~6分为术后临床症状改善不明显（P=0.000）。结论 SDAVFs切断术影像学治愈率极高，且相对于非手术治疗组的临床症状改善率亦较明显；根据相关预后因素（年龄、患病时间、迂曲扩张的引流静脉长度及患病当时的临床症状严重程度）提出的硬脊膜动静脉瘘手术预后评分系统，可用来评估预后。     

Dural arteriovenous fistulae at the foramen magnum

Spinal dural arteriovenous fistulae (DAVF) affect predominantly levels of the lower thoracic and lumbar segments; only 13 cases have been reported of DAVF at the foramen magnum. We present three surgically treated patients with DAVF at the foramen magnum. In none of our three patients could the site of the arteriovenous fistula be suspected from the clinical presentation. The clinical course varied form acutely developing signs and symptoms to a 10-year history of very slowly progressing symptoms. After neuroradiological diagnosis the patients were operated on direct microsurgical disconnection of the arteriovenous shunt via an enlargement of the foramen magnum and a hemilaminectomy of C1. DAVF at the foramen magnum may thus present with slowly to acutely progessing clinical symptoms and signs. Spinal angiographic examination should include the level of the foramen magnum if standard spinal angiography of thoracic, lumbar, and sacral segments is negative in suspected spinal DAVF since the nidus of the shunt can be situated remote from the level of neurological disorder. DAVF at the foramen magnum can be treated very effectively and with minimal surgical trauma by direct microsurgical disconnection of the shunt. This surgical procedure is indicated if embolization with glue is not possible or is unssuccessful. Received: 10 May 2000, Received in revised form: 14 August 2000, Accepted: 1 October 2000     

小脑幕硬脑膜动静脉瘘临床及影像学特点

目的总结小脑幕硬脑膜动静脉瘘（DAVF）的临床表现及影像学特点。方法回顾分析11例小脑幕DAVF病例的临床及影像学资料。结果本组男7例,女4例,平均年龄56．2岁;急性起病6例,亚急性起病2例,慢性起病3例;临床主要表现头痛、头晕、恶心、呕吐、眼震、共济失调等;头颅CT联合MRI检查可提示颅内出血性病变、非出血性病变、血管流空或异常血管影;DSA检查可清楚显示小脑幕DAVF瘘口、供血动脉和引流静脉。结论小脑幕DAVF临床表现多变,一些MRI特征性改变可提供小脑幕DAVF诊断线索,但确诊依赖DSA检查。     

Venous congestive myelopathy in spinal dural arteriovenous fistula mimicking neoplasia

Spinal dural arteriovenous fistulas (SDAVF) are the most common acquired arteriovenous shunts that occur in adults. By increasing venous pressure in the spinal venous system they are a cause of venous congestive myelopathy. We report the case of a patient with a SDAVF mimicking, on magnetic resonance imaging, the presence of a spinal cord tumour due to an unusual pattern of enhancement after gadolinium administration.     

海绵窦区硬脑膜动静脉瘘

目的:探讨海绵窦区硬脑膜动静脉瘘的病因、发病机理、临床症状反诊断、治疗方法。方法:23例病人应用微导管技术,在数字减影血管造影(DSA)监视下,对海绵窦区硬脑膜动静脉瘘行血管内栓塞治疗。5例单纯用颈动脉压迫法治疗。结果:28例中,23例应用上述方法治愈,治愈率为82.1％。4例症状明显改善,1例好转。结论:应用颈动脉压迫法及微导管技术栓塞治疗海绵窦区硬脑膜动静脉瘘是有效的治疗手段。     

硬脊膜动静脉瘘(附1例临床分析)

目的探讨硬脊膜动静脉瘘(SDAVF)的病因、发病机制、临床表现、诊断及治疗。方法回顾性分析了1例患者的相关临床资料。结果本例患者以双下肢渐进性麻木、无力1年余,加重伴大小便障碍9个月为主要临床表现,脊髓MRI显示T9~L1髓内以长T2长T1为主之异常信号,超选择DSA造影可见位于入LT12椎管处一硬脊膜动静脉之瘘口,成功地进行了经单侧椎板开窗夹闭瘘口术。结论SDAVF为一具有直接的动静脉交通性病变,常伴有小型畸形团,多发生于中年男性,误诊率高,主要表现为渐进性的肢体麻木、无力及大小便障碍,MRI有助于诊断,但仍须DSA确诊。阻断连接瘘口与冠状静脉丛的引流静脉是治疗SDAVF的有效方法,显微外科手术效果可靠、复发率低,尽早地确诊和治疗是取得良好疗效的根本前提。     

脊髓动静脉性血管病变的诊断与治疗(附99例报告)

目的探讨脊髓动静脉性血管病变(SCAVLs)的诊断与治疗。方法自1990年8月至2006年8月,我们收治99例SCAVLs,并回顾性分析他们的影像学改变、治疗方法与结果。结果99例脊髓动静脉性血管病变中,行手术治疗65例,介入治疗34例。手术治疗病例中,脊髓动静脉畸形(SAVM)31例、硬脊膜动静脉瘘(SDAVF)26例和髓周动静脉瘘(PMAVF)8例,各型SCAVLs病例术后获好转者分别为19例、17例和4例。结论脊髓MRI和DSA是正确诊断本病的关键。对SDAVF和Ⅰ型PMAVF宜首选手术治疗,对SAVM应尽可能采用手术切除(或术前辅以栓塞治疗)畸形灶,对Ⅱ型或Ⅲ型PMAVF宜取介入治疗或介入与手术联合治疗。治疗时,应针对动静脉短路进行根治性治疗,即手术和/或栓塞来闭塞瘘口和去除畸形灶。     

硬脊膜动静脉瘘五例误诊分析

目的探讨硬脊膜动静脉瘘的临床特点及误诊原因。方法分析5例确诊的硬脊膜动静脉瘘的临床、MRI及DSA表现。结果 5例中仅1例急性起病,表现为一侧肢体无力,误诊为急性脑梗死;余4例均慢性病程,表现为双下肢无力和麻木,部分伴有尿频和便秘。其中2例误诊为腰椎间盘突出,2例误诊为多发性硬化,1例误诊为脊髓炎,并予激素治疗后症状无明显好转,仍进行性加重。结论本病早期临床表现无特异性,容易误诊,脊髓MRI为首选,及时行此检查是避免误诊的关键;选择性的脊髓血管造影是诊断本病的金标准。     

椎动脉动静脉瘘的血管内治疗

目的探讨椎动脉动静脉瘘的临床特点及其治疗方法。方法对1997～2009年收治的5例椎动脉动静脉瘘病人均给予血管内栓塞治疗，其中1例表现搏动洼包块者另行手术治疗。结果5例病人均达到即刻全部栓塞，临床症状好转，没有发生并发症。5例病人中仅1例瘘口被闭塞而保持椎动脉通畅，其余4例均需要牺牲椎动脉才能闭塞异常血流。结论血管内栓塞治疗椎动脉动静脉瘘是一种安全有效的治疗方法。     

Immunohistochemical study in dural arteriovenous fistulas and possible role of local hypoxia for the de novo formation of dural arteriovenous fistulas

OBJECTIVE: Although previous clinical and experimental studies investigated the pathogenesis of dural arteriovenous fistulas (DAVFs), the biological process leading to intracranial DAVFs so far remains unknown. In this study, we investigated the expression of vascular growth factors in order to elucidate the possible role of these factors in the development of DAVFs. METHODS: We examined the histological features, proliferative and angiogenic capacities of the tissue specimens obtained from eight patients who underwent surgery at our institution. Immunohistochemical staining for vascular endothelial growth factor (VEGF), its receptors Flk-1 and Flt-1, transforming growth factor alpha (TGFalpha), basic fibroblast growth factor (bFGF), hypoxia inducible factor 1alpha (Hif-1alpha), MIB-1 and proliferating cell nuclear antigen (PCNA) was performed using standard immunohistochemical techniques. RESULTS: A positive immunostaining was found for all antibodies studied except MIB-1, whereas nuclear endothelial expression of PCNA was observed in only 3/8 cases. Hif-1alpha and VEGF stained positive in all of the available specimens (7/7). Flk-1 showed a positive immunoreaction in only 2/8 cases and Flt-1 in 5/7 cases. TGFalpha and bFGF were expressed in the majority (6/8) of cases. CONCLUSION: These results indicate the possible role of local tissue hypoxia as the initial step causing neoangiogenesis and a low degree of endothelial proliferation in DAVFs. Such hypoxia might be caused by venous hypertension or venous thrombosis as it was previously suggested by other authors.     

Double spinal dural arteriovenous fistulas

Background

Spinal dural arteriovenous fistulas (SDAVF) are usually solitary lesions. Synchronous and/or metachronous double SDAVF have rarely been reported in the literature. We report on three patients with double SDAVF and present our single center experience in the diagnostic and treatment management in these patients.

Relative signal intensity on time-of-flight magnetic resonance angiography as a novel indicator of aggressive presentation of intracranial dural arteriovenous fistulas

Asymptomatic dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) are now more commonly encountered. However, patients with an incidental onset may have a less aggressive clinical course. It is desirable to explore methods and indicators to predict the clinical outcomes. This study investigates whether the relative signal intensity (rSI) of the draining vessels on the time-of-flight magnetic resonance angiography is related to clinical behavior in patients with intracranial DAVFs. We retrospectively reviewed 36 intracranial DAVFs. The patients were categorized as those with either aggressive-presentation or non-aggressive-presentation (n = 16 and 20, respectively). The rSIs of the shunt points, affected sinuses, and veins with CVR were compared between the two groups. The two groups were not significantly different in terms of rSIs of the shunt points and affected sinuses (p = 0.37 and 0.41, respectively). However, a significant positive correlation was observed in the rSI of the veins with CVR between the aggressive and non-aggressive behavior groups (p < 0.0001). The rSI of the veins with CVR could serve as a reliable indicator of aggressive behavior in intracranial DAVFs, and its optimal cutoff value was 1.63 with high sensitivity and specificity for predicting aggressive behavior (area under the curve, 0.909).     

侧窦区硬脑膜动静脉瘘的血管内介入治疗

目的本文报道我科对连续收治的10例侧窦区(横窦和乙状窦)硬脑膜动静脉瘘(DAVF)行超选择性动脉内栓塞的初步经验。方法所有病人先进行脑血管造影,确诊为侧窦区DAVF后立即对供血动脉行超选择性造影术并用NBCA胶或PVA颗粒进行栓塞。结果10位病人进行16次栓塞治疗(有6例行2次),共对23根供血动脉进行了栓塞。其中8例采用NBCA胶,另2例采用PVA颗粒进行栓塞。8例栓塞后获得解剖学和临床治愈,另2例虽获临床治愈,但造影中仍可见少量病灶残留。4例伴有搏动性耳鸣和杂音者在首次栓塞后其症状和体征消失,其中1例搏动性耳鸣在第一次部分栓塞后2个月复发,但在第二次栓塞后消失。无一例病人在栓塞后出现并发症。结论超选择性动脉内栓塞治疗对于某些类型的侧窦区DAVF是一个安全、有效和微侵袭的治疗方法。     

Isolated asymptomatic pulmonary arteriovenous malformation presenting with ischaemic stroke

Young onset stroke is uncommon, and may be due to conditions other than traditional vascular risk factors. A 42-year-old woman with an ischaemic stroke was found to have left atrial bubble study positivity on transthoracic echocardiogram (TTE) suggestive of patent foramen ovale, however she also had low peripheral oxygen saturation. Investigation revealed an isolated pulmonary arteriovenous malformation (PAVM), visible on admission chest radiograph. This can cause embolic stroke and is an alternate cause of the TTE findings. The PAVM was able to be closed via endovascular intervention, removing the shunt and therefore removing her risk of recurrent stroke events. This is a rare cause of embolic stroke in young people which can be easily missed on investigation yet is amenable to treatment.     

复合手术治疗硬脊膜动静脉瘘31例分析

目的 探讨复合手术治疗硬脊膜动静脉瘘（SDAVF）的疗效。方法 回顾性分析2014年8月至2019年7月复合手术治疗的31例SDAVF的临床资料。术中DSA技术定位瘘口,据造影结果调整动脉夹,并验证瘘口闭塞的安全性和准确性。术后平均随访（28.9±2.7）个月,采用Aminoff-Logue评分（ALS）评价脊髓功能。结果 31例瘘口位置均准确定位,无扩大切口以暴露病灶,术后造影显示瘘口均消失。末次随访ALS[（3.3±0.5）分]较术前[（4.4±0.5）分]明显降低（P<0.05）;好转14例,无变化4例,加重2例,好转率为66.7%。随访期间无复发病例。结论 复合手术SDAVF安全、有效,与血管内栓塞相比,解决了其早期失败率及晚期复发率高的问题;与显微手术相比,实现了术中精准定位及实时效果评价。     

硬脑膜动静脉瘘Onyx栓塞术后三叉神经与面神经损伤一例

目的探讨硬脑膜动静脉瘘(DAVFs)Onyx栓塞术后并发三叉神经与面神经损伤的原因。方法分析1例DAVFs(海绵窦区)Onyx栓塞术后多发三叉神经与面神经损伤的临床资料,结合病因、临床表现、相应血管吻合。结果患者Onyx栓塞术后出现三叉神经及面神经损伤。结论硬脑膜动静脉瘘Onyx栓塞术后三叉神经与面神经的损伤与Onyx逆流阻塞相应脑神经的滋养动脉及二甲基亚砜的局部毒性有关。     

血管内栓塞治疗侧窦区硬脑膜动静脉瘘 （附10例报道）

目的 探讨侧窦（横窦-乙状窦）区硬脑膜动静脉瘘（LSDAVF）的血管内栓塞治疗的方法及有效性。方法 回顾性分析2011年7月至2016年6 月血管内栓塞治疗的10例LADAVF的临床资料,经右侧股动脉-颈外动脉-脑膜中动脉Onyx胶栓塞8例,经左侧股静脉-下腔静脉-颈内静脉球囊保护下 Onyx胶栓塞2例。结果 术后即刻造影完全栓塞8例,大部分栓塞2例,未出现并发症。术后随访6个月~2年,8例无加重及复发,2例异位复发。结论 血 管内栓塞治疗LSDAVF是一种相对安全、简单、有效的治疗方法,必要时需配合静脉窦球囊保护下进行;闭塞瘘口同时闭塞部分无功能静脉窦存在短期 内异位复发可能。     

4D-DSA在硬脑膜动静脉瘘诊治中的应用

目的 探讨4D-DSA在硬脑膜动静脉瘘（DAVF）诊断和治疗中的应用价值。方法 回顾性分析2018年3月到2019年10月采用4D-DSA诊断和指导血管内栓塞治疗的10例DAVF的临床资料及影像学资料,对其血管构筑学进行系统分析,并通过彩色血流全循环成像（iFlow）技术进行对比分析。结果 10例病人4D-DSA均可以清晰看到DAVF的瘘口（微孔复合体）、血管构筑和血流动力学流向,完成Cognard分型,并在4D-DSA引导下行血管内栓塞治疗。栓塞治疗后,10例病人iFlow结果显示患侧颈内动脉分叉部、大脑中动脉分叉部、窦汇区的造影剂达峰时间较术前明显缩短（P<0.05）。结论 4D-DSA不仅可以对DAVF的血管构筑学、血流动力学有直观地理解,完成其分型和分类,并且可优化手术治疗方案