颈动脉海绵窦瘘23例疗效探讨

目的总结23例颈动脉海绵窦瘘﹙CCF﹚的临床诊治经验并探讨治疗策略。方法回顾性分析23例各种类型CCF的诊治体会,患者:Barrow分型A型14例、B型1例、C型1例、D型7例。结果20例经动脉入路,2例静脉入路,1例放弃栓塞治疗。9例采用单纯球囊行瘘口栓塞,5例直接行患侧颈内动脉和瘘口闭塞;5例采用NBCA胶栓塞瘘口;1例采用明胶海绵颗粒部分栓塞联合颈动脉压迫治疗;2例采用弹簧圈海绵窦内栓塞;1例单纯采用颈动脉压迫治疗。21例痊愈,2例好转。结论CCF具有复杂性、难治性特点,血管内治疗应作为主要治疗手段。     

Balloon reconstructive technique for the treatment of a carotid cavernous fistula.

Endovascular treatment of carotid cavernous fistulas (CCFs) presents many technical difficulties and hazards, some unique to each patient. This report details some of the difficulties encountered in the treatment of a 63-year-old patient with a CCF and an ipsilateral internal carotid artery dissection. After failure of conventional techniques using a detachable balloon, complete closure of the CCF was achieved by transvenous coil embolization while the arterial lumen was protected by a nondetachable balloon catheter.     

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...     

经面静脉-眼上静脉入路治疗颈动脉海绵窦瘘

目的　评价经面静脉 眼上静脉入路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 眼上静脉入路对 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 ,面静脉痉挛闭塞 ,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 2 1天症状明显改善 ,造影检查发现瘘口已经消失 ,术后 1个月患者眼部症状完全消失。其他病例在栓塞术后眼部症状明显改善 ,     

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.     

Endovascular treatment of carotid cavernous fistulae (CCF). Direct venous puncture using road mapping in dural CCF

Introduction

Endovascular treatment offers different options to treat CCF by less invasive approach avoiding morbidity and residual fistulas. The choice depends on the anatomy of the fistula and operator/Institutional preferences.

Objective

Describe options in endovascular treatment of Barrow Type A and Type D Carotid Cavernous fistulas (CCF).

Patients and methods

We report 10 cases of carotid cavernous fistula (CCF) that received endovascular treatment using coils and liquid embolic materials. Seven cases Barrow Type A, done through an arterial approach and three cases Barrow Type D, done through venous approach. The cavernous sinus in Type D cases was approached via the inferior petrosal sinus in one case and the other two cases by direct puncture of the facial and supra-orbital veins using road mapping. Using road mapping in venous approach to treat CCF is not reported in the literature before.

Results

Successful obliteration of the fistula was achieved in all cases with transient VI nerve palsy in one case and post procedure ophthalmic vein thrombosis in another.

Conclusion

With the observed favorable outcomes and lack of significant procedural morbidity, direct puncture of the facial and supra-orbital veins using road mapping to reach the cavernous sinus, might be an addition in the armamentarium available for endovascular treatment of CCF.     

双导管球囊技术治疗高流量颈动脉海绵窦瘘

目的探讨双球囊导管技术治疗高流量颈动脉海绵窦瘘(CCF)的可行性及疗效。方法随机选择1枚可脱性球囊无法闭塞的CCF患者3例,双侧股动脉置管,送2枚球囊进入瘘口,调整位置,充盈2枚球囊,使瘘口完全闭塞后再解脱球囊,观察栓塞效果和颈内动脉通畅情况,评价该技术的可行性。结果3例患者均1次性完全闭塞瘘口,颈内动脉皆通畅,操作过程简单易行,未增加介入治疗的危险性。结论双导管球囊技术能在保证颈内动脉通畅的前提下简单有效地治疗1枚球囊无法闭塞的CCF。     

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。     

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas （CCF） and their complications such as pseudoaneurysms. Methods： Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coll embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stem management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% （4/22）. A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% （8/22）. Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.     

可脱球囊栓塞术在海绵窦瘘治疗中的应用 (附 2 7例报告 )

目的　研究微导管可脱球囊技术治疗海绵窦瘘的临床意义。方法 :2 6例外伤性颈内动脉海绵窦瘘 (TCCF)患者和 1例大脑前动脉 (A1段 )动脉瘤破裂合并海绵窦瘘患者采用微导管可脱球囊技术进行栓塞治疗 ,以经颅多普勒 (TCD)进行复查 ,所有患者均随访 6月以上。结果 :2 2例CCF患者均成功栓塞瘘口并保持颈内动脉通畅 ,其中 2 0例为一次栓塞成功 ,2例因球囊过早泄漏而行 2次栓塞治疗。对 1例A1段动脉瘤破裂合并海绵窦瘘患者成功施行了双球囊动脉瘤颈孤立术。 4例行颈内动脉闭塞术。本组病例未发生严重并发症。结论 :微导管可脱球囊技术是对海绵窦瘘的一种微创、安全、有效的治疗方法。     

Ehlers–Danlos syndrome type IV and recurrent carotid-cavernous fistula: review of the literature, endovascular approach, technique and difficulties

We report the follow-up of a previously published case (Forlodou et al. Neuroradiology 38:595–597, 1996) of carotido-cavernous fistulas (CCFs) in a patient presenting with type IV Ehlers–Danlos syndrome (EDS 4) that were successfully treated twice by an endovascular approach. Initial treatment with a detachable balloon was in 1994 for a right CCF, and, 8 years later, a left CCF was treated by selective transarterial occlusion of the cavernous sinus with coils. Unfortunately, the patient suffered from a spontaneous post-operative intracranial haemorrhage in the left hemisphere and died. Review of the literature, technical considerations for bilateral CCF and complication are discussed.     

28例颈动脉海绵窦瘘血管内栓塞治疗的影像学研究

报告２８例各型颈动脉海绵窦瘘血管内行可脱球囊或固体栓子栓塞治疗，其中９例经眼上静脉逆行插管栓塞海绵窦，均获成功。２５例有外伤史，１５例确定瘘口位置。海绵窦瘘分型：Ａ型：２３例；Ｂ型：１例；Ｃ型：２例；Ｄ型：１例；Ａ＋Ｃ型：１例。２５例海绵窦主要通过眼静脉引流，眼上静脉扩张平均值为０．７６ｃｍ，１３例有不同程度“偷流”现象。栓塞后造影，海绵窦和引流静脉消失。作者强调，血管造影是为各型瘘提供手术入路和愈后评价的客观依据，并对眼上静脉入路栓塞治疗的可行性进行了探讨。     

颈内动脉海绵窦瘘血管内栓塞治疗的临床价值

目的　探讨颈内动脉海绵窦瘘的血管内栓塞治疗。方法　对 18例外伤性颈内动脉海绵窦瘘患者 ,全部经皮股动脉穿刺行全脑DSA检查确诊 ,用可脱球囊进行栓塞治疗。结果　 18例患者全部栓塞成功 ,其中 15例同时保持颈内动脉通畅 ,1例CCF瘘口较大 ,2例球囊进入瘘口困难 ,改行闭塞瘘口的同时栓塞同侧颈内动脉。术后除 1例患者眼睛失明未恢复外 ,其余病例临床症状及体征完全消失。结论　血管内栓塞技术是目前治疗CCF的最好方法 ,具有损伤小 ,安全性高 ,疗效可靠等特点     

Ruptured cavernous sinus aneurysms causing carotid cavernous fistula: incidence, clinical presentation, treatment, and outcome

BACKGROUND AND PURPOSE: In this study, we present our experience with 11 patients with ruptured cavernous sinus aneurysms causing carotid cavernous fistulas (CCFs), to assess the incidence of ruptured cavernous sinus aneurysms causing CCFs and evaluate clinical presentations, treatments, and outcomes. PATIENTS AND METHODS: During a 10-year period, 10 of 689 (1.5%) endovascular-treated ruptured aneurysms were ruptured cavernous sinus aneurysms causing CCF. One additional patient with a CCF died shortly before treatment of intracranial hemorrhage. All patients had audible pulsatile bruit. Exophthalmus, ocular motor palsy, and decreased vision correlated with venous drainage to the superior ophthalmic veins and intracerebral hemorrhage was associated with major cortical venous drainage in 2 patients. RESULTS: Two low-flow CCFs closed spontaneously before treatment with resolution of symptoms; the aneurysms were subsequently treated. Eight CCFs were successfully occluded, 5 by coil occlusion of the aneurysm, one by occlusion of the aneurysm with a balloon, and 2 by simultaneous coil occlusion of the aneurysm and internal carotid artery. There were no complications of treatment. Visual acuity returned to normal in all but one patient, and ophthalmoplegia was cured in 6 of 8 patients. In 2 patients, a remaining abducens palsy was surgically corrected. CONCLUSION: The incidence of CCF by a ruptured cavernous sinus aneurysm was 1.5%. CCF was the presenting symptom in 24.4% of treated symptomatic cavernous sinus aneurysms. Clinical symptoms correlate with venous drainage. Drainage to cortical veins may lead to intracranial hemorrhage. Endovascular treatment with coils is effective in occluding the fistula.     

Direct puncture of the proximally occluded internal carotid artery for treatment of carotid cavernous fistulas

Three patients with symptomatic carotid cavernous fistulas (CCFs) characterized by complete occlusion of the proximal internal carotid artery were treated by percutaneous puncture and embolization. Two patients had CCFs associated with traumatic dissections of the internal carotid artery and were treated initially with trapping procedures. Both patients had persistent symptoms related to the CCF and underwent additional surgical procedures (ophthalmic artery ligation and intraoperative embolization) without improvement. The third patient had traumatic occlusion of the internal carotid artery. After direct percutaneous puncture of the carotid artery above the occlusion, a catheter was advanced into the petrous internal carotid artery. Balloons (one case) or coil emboli (two cases) were placed into the cavernous sinus to produce CCF closure. There were no complications from this procedure. Direct puncture of the carotid artery is an alternative treatment for patients lacking safe access for CCF embolization.     

Transorbital hybrid approach for endovascular occlusion of indirect carotid-cavernous fistulas–Case report and systematic literature review

Carotid-cavernous fistulas (CCF) are vascular malformations characterized by an aberrant shunt between one or more sources of arterial inflow and the cavernous sinus (CS). They are subdivided into direct and indirect fistulas. This last one, called dural CCF involve dural fistulous connections between branches of the internal carotid artery or the external carotid artery. When conventional routes are not eligible, surgical exposure of the vein is the only access to the fistula. We present the case of a patient successfully treated for right sided dural CCF, by a hybrid approach. Furthermore, through a literature review, we analyze the possible risks and benefits associated with this approach.     

颅底动脉损伤的介入治疗

目的 探讨多种血管腔内手段治疗颅底动脉损伤的临床价值.方法 2004年10月至2007年5月间我院收治各类型颅底动脉损伤患者共53例,均有头颈部外伤史.主要症状为搏动性突眼和颅内血管杂音(39例)、声嘶或吞咽不适(9例)、鼻出血(5例)等;DSA检查证实颈动脉海绵窦瘘(carotid cavemous fistulae,CCF)39例,颈内动脉假性动脉瘤14例;针对上述53例患者不同的病变特点采用不同的血管腔内治疗,并通过电话或门诊随访.结果 对53例患者56支颈内动脉进行了腔内介入治疗,采用单纯可脱球囊栓塞治疗CCF'33例34支血管,可脱球囊联合弹簧圈栓塞3例,植入覆膜支架封堵CCF3例;采用单纯可脱球囊闭塞颈内动脉治疗假性动脉瘤8例,可脱球囊联合弹簧圈孤立假性动脉瘤2例,植入覆膜支架腔内隔绝治疗4例;平均随访时间9.5个月(2～25个月),85%(45/53)患者主诉症状于6个月内消失,12个月随访15%(8/53)患者遗留眼球运动受限或视力障碍.复查显示存在假性动脉瘤6例,残瘘3例,其中2例因海绵窦区的硬脑膜动静脉瘘而分别于术后第2、3个月行再次介入治疗.结论 对各型颅底动脉损伤,血管腔内介入治疗创伤小且安全有效.尽管存在缺陷,可脱球囊仍是治疗CCF和颈动脉假性动脉瘤的首选方法,在特殊情况下必需联合应用弹簧圈栓塞和覆膜支架植入等多种治疗手段.     

Ruptured aneurysm of the anomalous cerebellar artery originating from internal carotid artery presenting with carotid cavernous fistula: a case report

We report a case of a ruptured aneurysm of the anomalous cerebellar artery originating from internal carotid artery presenting with a carotid cavernous fistula (CCF). An initial angiogram showed the typical appearance of a CCF with a direct fistulous tract with focal aneurysmal dilation from the ascending cavernous segment of the right internal carotid artery. A postembolization angiogram of the right internal carotid disclosed the anomalous cerebellar artery originating from the fistula point of the internal carotid artery.     

颈动脉海绵窦瘘的血管内栓塞治疗

目的　探讨不同的栓塞材料在颈动脉海绵窦瘘 (CCF)的血管内栓塞治疗中的应用。方法　回顾分析了 2 3例CCF血管内栓塞治疗病例。其中 2 2例外伤性CCF ,19例使用了可脱性球囊 ,3例使用了金属微弹簧圈作栓塞材料 ;1例自发性CCF ,使用了NB CA胶作栓塞剂。结果　可脱性球囊栓塞 19例 ,均获得临床治愈 ,其中 12例保持了患侧颈内动脉的通畅 ,获得解剖治愈 ;金属微弹簧圈栓塞 3例 ,2例成功 ,1例因弹簧圈异位栓塞于右大脑中动脉的分支 ,导致病人失语和半身不遂 ,1例自发性CCF ,经患侧脑膜副动脉注射NBCA胶 ,部分NBCA进入海绵窦内 ,病人获得临床治愈。结论　CCF首选血管内栓塞治疗 ,而可脱性球囊是一种理想的栓塞材料。由于金属微弹簧圈可控性差 ,不够安全 ,不应再被作为经颈内动脉途径的栓塞材料。     

创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊断和治疗

目的 探讨创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤的诊疗方法.方法 介入方法诊断和治疗6例创伤性颈动脉海绵窦瘘合并蝶窦假性动脉瘤患者.结果 5例出现反复鼻腔大出血;所有患者均行瘘口和假性动脉瘤球囊闭塞,2例颈内动脉保留,1例合并对侧间接型颈动脉海绵窦瘘行经面静脉-眼上静脉瘘口弹簧圈栓塞术.术后颅内杂音均即刻消失,结膜充血水肿2周～3个月内消退.无介入相关并发症.所有患者均行随访,无临床症状复发,均恢复工作.结论 车祸是致颈动脉海绵窦瘘合并蝶窦假性动脉瘤的主要原因;受力部位多集中在患侧眶额部到眶颧部的眶前外侧区;头颅MRI结合临床表现对于术前确诊该病非常有帮助;可脱球囊闭塞瘘口和假性动脉瘤或闭塞颈内动脉是安全、有效的治疗方法.