硬脑膜动静脉瘘的治疗

目的　探讨不同方法治疗不同类型的硬脑膜动静脉瘘 (DAVF)的疗效。方法　采用经动脉入路在供血动脉内采用低浓度NBCA胶、弹簧圈、游离纤毛钢圈、PVA等栓塞治疗 ;经静脉入路在瘘口静脉端用弹簧圈栓塞 ,或直接开颅手术夹闭瘘口、静脉窦表面颅骨钻孔后直接穿刺作静脉窦内栓塞及静脉内支架植入等方法治疗不同部位和不同类型的DAVF 32例。结果　 8例前颅凹底DAVF ,5例经动脉入路栓塞治疗 ,2例治愈 ,3例临床好转 ;3例 (1例经静脉入路治疗失败后 )前颅凹底入路行开颅瘘口直接夹闭治愈。 14例海绵窦区DAVF ,7例经眼上静脉入路海绵窦内栓塞治愈 ,4例经动脉入路 ,治愈 1例 ,好转 3例。 5例横窦区DAVF ,2例经静脉入路窦内栓塞治愈 ,2例动脉入路栓塞后好转 ,1例行窦孤立手术治愈。 4例多处瘘口的上矢状窦DAVF ,联合多种治疗方法经多次治疗 ,临床好转。 1例左侧颈静脉孔区DAVF联合多种治疗方法经多次治疗治愈。结论　前颅凹底DAVF以直接手术行瘘口夹闭疗效好 ,经动脉入路低浓度胶栓塞可治愈但需注意危险吻合 ;海绵窦区DAVF经静脉入路栓塞多可治愈。横窦区DAVF静脉入路栓塞瘘口静脉端效果好 ;复杂性DAVF治疗困难 ,目前联合多种治疗方法可以达到临床改善。将治疗策略定在针对瘘口的静脉端 ,可望达到临床治愈。

Management of dural arteriovenous fistula

Objective To report our experience on treatment of dural arteriovenous fistula with various methods to investigate its efficacy. Methods We treated the DAVF patients with transarterial NBCA, GDC, free fibril coils and PVA embolization, transvenous coil embolization at the fistula or endovascular stenting, fistula clipping in cranioctomy. Results Five in 8 cases with DAVF in anterior cranial fossa were cured and 3 improved clinically. Eleven in 14 patients with DAVF in cavernous region were cured and 3 improved clinically. Among five cases with DAVF in transverse sinus, 2 were cured by transvenous intrasinus embolization and one by sinus isolation, 2 improved after transarterial embolization. Four patients with multiple fistulae in DVAF involving superior sagittal sinus improved by combined treatment. One patient with DAVF in jugular venous region were treated by multiple sessions with combined methods. Conclusions Direct clipping is effective in treatment of DAVF in anterior cranial fossa. DAVF in transverse sinus and cavernous sinus can be cured by transvenous approach. Combined endovascular and surgical treatment should be considered for complicated DAVF, focusing on embolization of venous part of the fistulae.