海绵窦区硬脑膜动静脉瘘血管内介入治疗的临床研究

发布时间：2018-06-28 04:07

  本文选题：硬脑膜动静脉瘘 + 海绵窦　； 参考：《南方医科大学》2015年博士论文

【摘要】：颅内硬脑膜动静脉瘘(dural arteriovenous fistulas, DAVFs)占颅内动静脉畸形的10%-15%。DAVFs可发生于硬膜及其附件的任何部位。海绵窦区硬脑膜是最常见的发生部位之一。海绵窦区硬脑膜动静脉瘘(Cavernous sinus dural arteriovenous fistulas, csDAVFs)常有许多起源于颈内动脉或颈外动脉细小的供血动脉,并且常累及双侧海绵窦,因此通过外科手术切除较为困难。而放射治疗起效的时间过长且疗效不确切,因此不适宜作为一线治疗方式。血管内治疗已发展成为治疗csDAVFs的首要的治疗策略。Onyx液体栓塞系统是近年来出现的栓塞剂,具有弥散性能好、低黏性且聚合较慢的特点。所有这些性质使得Onyx允许更长时间的注射及更好的控制能力。与其它栓塞剂对比,现在Onyx已更频繁地用来治疗DAVFs。但目前临床上对csDAVFs的治疗不规范,有些病例存在治疗困难。因此将本文重点探讨在应用Onyx的背景下如何有效地应用血管内介入栓塞的方法治疗csDAVFs。第一章有效地应用弹簧圈联合Onyx栓塞海绵窦治疗海绵窦区硬脑膜动静脉瘘研究背景和目的应用Onyx联合弹簧圈经静脉入路栓塞海绵窦以治疗csDAVFs已成为该病首选的治疗方法,但是常常由于手术操作相关的并发症较多,比如不全栓塞致颅内出血,海绵窦内或海绵窦壁内颅神经受刺激导致相应的并发症,术中出现心率下降甚至心跳停跳的问题等。这些都是应该在治疗中该注意及解决的问题。因此本文将结合我们的病例,总结我们的治疗经验,介绍如何有效地应用Onyx联合弹簧圈栓塞海绵窦以治疗csDAVFs。方法与材料1.收集临床资料回顾性分析自2008年8月至2013年2月使用Onyx或联合弹簧圈经岩下窦入路栓塞海绵窦治疗csDAVFs的病人资料。详细回顾全部的临床记录、影像学资料及操作记录。排除资料缺失、既往有颅内疾病治疗史及患有其他可能严重影响患者的预期寿命疾病的病人。所有病人均按Borden-Shucart分类及Barrow分类方法进行分型。2.治疗方法所有患者住院期间均接受经股动脉脑血管造影检查,术中持续给予肝素以保持每个病人的活化凝血时间在200s至300s间。造影包括双侧颈内动脉、双侧颈外动脉及椎动脉造影,以确认瘘口的位置、供血动脉及引流静脉等信息。所有病人均经股静脉-岩下窦入路进行栓塞。我们将一根6F指引导管置入颈内静脉内,利用一根微导管在微导丝的辅助下经过同侧或对侧岩下窦进入海绵窦内。将一根5F诊断性造影导管放置在颈外动脉或颈内动脉内,利用路图技术标出靶点位置。首先,我们评价血流动脉学的特点,若在动脉期或毛细血管期存在逆向充盈的引流静脉,则将部分弹簧圈放置在引流静脉的出口附近,在注射Onyx前将微导管的头端置入弹簧圈的网眼中。溶度为6%的Onyx(18)在监视下被缓慢注入海绵窦内。如果Onyx弥散入非目标区,我们就停止注射约20秒至2分钟,试图让Onyx产生聚合作用以达到改变弥散方向的目的,我们也会调整微导管头端的位置以使Onyx达至更好的弥散效果。我们的目标是使Onyx成功地弥散入海绵窦的每个部分。3.评价标准影像学的评价标准为：(1)完全栓塞,没有可以辨认的动静脉分流；(2)次全栓塞,只有小的停滞不前的残存分流而无皮层静脉或眼静脉的引流；(3)不完全栓塞,只有流量的减少而有明显的分流残存。完全及次全栓塞被认为是成功的血管造影结果。临床的评价标准为：(1)无症状；(2)改善,原有症状的明显改善；(3)无改善,症状无改变或加重；(4)复发,随访期新发的与病变相关的症状。无症状及症状明显改善被认为是临床治愈。4.观察方法对比患者栓塞前的脑血管造影的影像资料、术后即刻脑血管造影影像资料、及随访脑血管造影的影像资料,以确定影像学的治疗效果。观察患者出院时及随访期的临床症状与体征,与入院时的临床症状与体征对比,以确定临床治疗效果。观察并发症的转归情况。5.统计学方法利用SPSS 19.0统计软件进行分析。平均年龄、平均Onyx使用量、平均弹簧圈使用数量及体积采用算数平均数表示,平均临床随访期采用中位数表示。结果共收集到25个资料完整的病人,包括14个女性,11个男性,年龄从16岁至70岁(平均46.88±13.28岁)。根据Barrow分型,1个病人属于C型,24个病人属D型。根据B orden分型,20个病人属于I型,5个病人属于II型。11例累及左侧海绵窦,8例累及右侧海绵窦,6例累及双侧海绵窦。所有病人均有结膜充血(100%,25/25),24个病人有突眼(96.0%,24/25),17个病人有球结膜水肿(68.0%,n=17)。共实施了25个栓塞程序。共有3个病人单用Onyx,其余22个病人使用Onyx及弹簧圈。使用弹簧圈的数量为2-5个(平均2.55±0.91个),体积范围为8.04 mm3至91.04 mm3 (平均32.15±16.03 mm3), Onyx平均使用量为2.57±0.86m1。术后即刻造影显示所有病人取得了成功栓塞,其中,22(88.0%)个病人取得了完全栓塞,3(12.0%)病人取得了近完全栓塞。该3个病人术后3个月行脑血管造影复查,均发现取得了完全栓塞。其余的22个病人,术后6个月的脑血管造影未发现复发。出院时7(28.0%)个病人表现出无症状,余18个病人表现为症状明显改善。所有25个病例,临床随访间期为6至49个月(中位数时间为10个月)。在取得症状改善的病人中,临床症状在术后2周至3个月内逐渐消失。所有病人在随访终点均保持无症状。共6(24.0%)个病人发生并发症。1个病人表现为对侧眼力模糊,1个病人为复视加重,2个病人术中发生暂时性的心动过缓,1个病人表现为同侧展神经麻痹,1个病人表现为同侧眼睑水肿。所有并发症均治愈。结论有效地应用Onyx及弹簧圈栓塞海绵窦是成功治愈海绵窦区硬脑膜动静脉瘘的关键。合理放置弹簧圈的位置,有效地运用Onxy弥漫性及控制性好的特点,避免过量使用弹簧圈及Onxy,是有效治愈csDAVFs并减少并发症发生的有益的理念。第二章经动脉入路使用Onyx栓塞经静脉入路栓塞失败的海绵区硬脑膜动静脉瘘研究背景和目的经静脉入路栓塞海绵窦已成为治疗csDAVFs的最优先的选择,尽管偶尔经静脉插管存在困难。在我们中心经静脉栓塞海绵窦以治疗csDAVFs也已成为治疗该病的优先选择。然而,经常规的岩下窦或眼上静脉插管入海绵窦偶尔会失败。此时,被建议行外科插管至眼上静脉或经皮经眶穿刺插管入海绵窦,但这会带来许多并发症,比如眶内血肿或者感染,及损害相邻的颅神经。一些神经介入医师偿试使用皮层静脉如颞浅静脉及大脑中浅静脉作为路径插管至海绵窦,然而,暴露这些皮层静脉需要行开颅手术及复杂的程序。使用液体栓塞剂经动脉路径栓塞海绵窦区硬脑膜动静脉瘘有较高的风险,在于可能栓塞颈外动脉与颈内动脉的脑膜支间存在的危险吻合血管、神经滋养血管、眼动脉及椎动脉。由于Onyx具有聚合性良好及低黏合性的特点,有助于控制胶在瘘的渗透,已成为治疗硬脑膜动静脉瘘首选的栓塞剂。已经有人在偿试用Onyx通过动脉路径栓塞csDAVFs, Pero等报道了3例以咽升动脉路径应用Onyx栓塞csDAVFs的病例。Gandhi等报道了1例经颌内动脉远端分支为路径应用Onyx栓塞csDAVFs的病例。Amiridze等描述了1例通过脑膜中动脉及蝶腭动脉应用Onyx栓塞csDAVFs的病例。但这些个案报道均缺乏对动脉路径治疗策略及经验的总结。因此本文的主要目的是报道关于经动脉路径使用Onyx栓塞经静脉插管失败的csDAVFs的病人的治疗经验。方法与材料1.收集临床资料回顾性分析自2010年11月至2013年6月经静脉路径治疗失败,而后改行利用动脉路径Onyx栓塞瘘口的方式治疗的csDAVFs的病人的资料,详细回顾全部的临床记录、影像学资料及操作记录。排除资料缺失、既往有颅内疾病治疗史及患有其他可能严重影响患者的预期寿命疾病的病人。所有病人均按Borden-Shucart分类及Barrow分类方法进行分型。2.治疗方法所有病人均在在静脉全麻下经股动脉插管行常规的全脑血管造影术。肝素化维持活化凝血时间在200秒至300秒间。脑血管造影包括双侧选择性的颈内动脉、颈外动脉造影,及双侧椎动脉造影。确认包括瘘口的位置、供血动脉、静脉引流模式、侧支循环及危险血管吻合等信息。所有病人均优先偿试行静脉入路栓塞海绵窦。对经静脉插管失败的病人,我们采用经动脉路径的方法进行栓塞。将一根6F的指引管置入颈外动脉内,同时对对侧的股动脉进行穿刺插管进行对照脑血管造影检查。然后将一根微导管在一根微导丝的导引下置入尽量靠近瘘口的供血动脉的远端位置。再行超选择性造影以确定最佳的导管头端楔入位置,鉴别正常动脉血管支及危险吻合。在实时路图监控下使用“反流-停顿-再注射”技术缓慢注射Onyx。当发现胶返流入非目标区时,停止注入约20秒至2分钟,以让Onyx沉淀下来并在导管头端周围形成一个栓子。然后再重新注射,以尽可能地使Onyx弥漫入全部的瘘口而不栓塞危险吻合及重要的血管。3.评价标准影像的评价标准为：(1)完全栓塞,没有可以辨认的动静脉分流；(2)次全栓塞,只有小的停滞不前的残存分流而无皮层静脉或眼静脉的引流；(3)不完全栓塞,只有流量的减少而有明显的分流残存。完全及次全栓塞被认为是成功的血管造影结果。临床的评价标准为：(1)无症状；(2)改善,原有症状的明显改善；(3)无改善,症状无改变或加重；(4)复发,随访期新发的与病变相关的症状。无症状及症状明显改善被认为是临床治愈。4.观察方法对比患者栓塞前的脑血管造影的图像与术后即刻脑血管造及随访脑血管造影的图像,以确定影像学的治疗效果。观察患者出院时及随访期的临床症状与体征,与入院时的临床症状与体征对比,以确定临床治疗效果。观察并发症的转归情况。5.统计学方法利用SPSS 19.0统计软件进行分析。平均年龄、平均住院天数采用平均数来表示,平均随访期采用中位数表。结果共有8个病人经静脉路径栓塞失败,并且接受了经动脉路径的Onxy栓塞。分别有4男4女,年龄范围从26岁至57岁(平均37.88±10.64岁)。其中7个病人因微导管不能成功经静脉路径到达海绵窦,另有1个病人因病变侧的颈静脉球以下的颈内静脉闭塞。所有病人在经静脉路径栓塞失败前均未接受治疗。所有病人(100%,8/8)均有结膜充血,5个病人(62.5%,5/8)表现为突眼及球结膜水肿。经动脉路径共经历8次栓塞及8次插管操作,其中5例经脑膜中动脉插管,3例经脑膜副动脉插管。栓塞术后即刻造影显示7个病人(87.5%,7/8)取得了瘘的完全栓塞,1个病人(12.5%,1/8)取得了部分栓塞。所有病人在栓塞后的3至8天(平均5.5±1.6天)出院。所有病人术后均进行脑血管造影随访复查,平均随访期约6个月(间隔从6个至10个月)。在随访终末期所有病人取得了完全栓塞。两个病人发生与经动脉路径栓塞程序相关的并发症,1例发生与病变同侧的左侧的面部麻木感,另1例发生右侧展神经麻痹及球结膜水肿。经过治疗后,两例并发症均治愈。结论当经静脉路径栓塞海绵窦治疗海绵窦区硬脑膜动静脉瘘困难时,经动脉路径栓塞瘘管提供了一个安全且有效的选择。脑膜中动脉及脑膜副动脉为从动脉路径栓塞csDAVFs提供了较好的栓塞路径。
[Abstract]:The 10%-15%.DAVFs of dural arteriovenous fistulas (DAVFs), which accounts for intracranial arteriovenous malformations, can occur at any part of the dura and its appendages. The dura mater is one of the most common sites in the cavernous sinus. The cavernous sinus dural arteriovenous fistula (Cavernous sinus dural arteriovenous fistulas, csDAVFs) is often found. Many of the small blood supply arteries originating from the internal carotid artery or the external carotid artery often involve bilateral cavernous sinus, so it is more difficult to be excised by surgery. And the time of radiation therapy is too long and the curative effect is not accurate. Therefore, it is not suitable as a first-line treatment. Intravascular therapy has developed into a primary treatment strategy for the treatment of csDAVFs. The slightly.Onyx liquid embolic system is a recent embolic agent which has the characteristics of good dispersion, low viscosity and slow polymerization. All these properties allow Onyx to allow longer injection and better control. Compared with other embolic agents, Onyx is now more frequently used for the treatment of DAVFs. but is now clinically treated for csDAVFs. It is not standardized and some cases are difficult to treat. Therefore, this article focuses on how to effectively apply endovascular embolization in the context of the application of Onyx in the first chapter of csDAVFs. to effectively apply the coils combined with Onyx cavernous sinus for the treatment of the cavernous sinus dural arteriovenous fistula in the cavernous sinus area and to apply the combination of the Onyx spring Embolization of cavernous sinus via venous approach to treat csDAVFs has become the first choice for the treatment of the disease. However, there are often many complications related to operation, such as intracranial hemorrhage caused by incomplete embolism, the stimulation of the cranial nerves in the cavernous sinus or the cavernous sinus, resulting in the corresponding complications, the decline of heart rate and even the stop beating of the heartbeat during the operation. All these are the problems that should be paid attention to and solved in the treatment. Therefore, this article will combine our cases, summarize our treatment experience, introduce the effective application of Onyx combined with coils to embolized cavernous sinus to treat csDAVFs. method and material 1. to collect clinical data from August 2008 to February 2013 using Onyx or couplet. Embolization of cavernous sinus in the cavernous sinus for the treatment of csDAVFs patients with a coiling ring through the subpetal sinus approach. A detailed review of all clinical records, imaging data and operational records. Missing data, history of treatment of intracranial diseases, and other patients with life expectancy diseases that may seriously affect patients. All patients are classified according to Borden-Shucart and Barrow classification method for.2. treatment, all patients received arteriography of femoral artery and cerebral angiography during hospitalization. During the operation, heparin was continuously given to keep the activated coagulation time between 200s and 300s. The angiography included bilateral internal carotid artery, bilateral external carotid artery and vertebral artery angiography to confirm the location of the fistula and blood supply. All the patients were embolized by the femoral vein - the subpetrosal sinus approach. We placed a 6F guide tube into the internal jugular vein and used a microcatheter to enter the cavernous sinus through the ipsilateral or the inferior sinuses with the assistance of the microconductance. A 5F diagnostic fabrication catheter was placed in the external carotid artery or the internal carotid artery. In the first place, we evaluate the characteristics of the blood flow arteria. If there is a reverse filling vein in the arterial or capillary stage, we place a part of the spring ring near the outlet of the drainage vein and put the head end of the micro catheter into the net eye of the spring ring before the injection of Onyx. The solubility is 6% Onyx (18). If Onyx is diffused into the cavernous sinus under surveillance. If we diffuse into the non target area, we will stop injecting about 20 to 2 minutes, trying to make Onyx produce polymerization to change the direction of dispersion, and we will also adjust the position of the micro catheter end to make Onyx better dispersion effect. Our goal is to make Onyx successful. The standard evaluation criteria for.3. evaluation of each part of the cavernous sinus were: (1) complete embolization, no recognizable arteriovenous shunt; (2) subtotal embolism, only a small stagnant residual shunt without drainage of the cortical vein or eye vein; (3) incomplete embolism, and only a decrease of flow and obvious shunt remnants. Complete and subtotal embolism was considered as a successful angiographic result. Clinical evaluation criteria were: (1) asymptomatic; (2) improvement, obvious improvement of the original symptoms; (3) no improvement, no change or aggravation of symptoms; (4) recurrence, new symptoms associated with disease in the follow-up period. Asymptomatic and symptomatic improvement was considered as a clinical cure for.4. observation. In order to determine the clinical symptoms and signs of the patients at the discharge and follow-up period, the clinical symptoms and signs of the patients were compared with the clinical symptoms and signs at the time of admission to determine the clinical therapeutic effect. .5. statistical software was used to analyze the outcome of the complications. The mean age, the average age, the average use of Onyx, the average number of coils and the mean number of the coils were expressed by the mean number, and the median of the average clinical follow-up period was expressed in the median. The results were collected in 25 complete patients, including 14 women, 11, 11. A male, aged from 16 to 70 years (average 46.88 13.28 years old). According to Barrow classification, 1 patients belong to type C, 24 patients belong to type D. According to B Orden classification, 20 patients belong to I type, 5 patients belong to the II type.11 cases involving the left cavernous sinus, 8 cases involving the right cavernous sinus and 6 cases involving bilateral cavernous sinus. All patients have conjunctival congestion (100%, 25/25 24 patients had exophthalmos (96%, 24/25), 17 patients with conjunctival edema (68%, n=17). A total of 25 embolic procedures were carried out. A total of 3 patients used Onyx alone, and the other 22 patients used Onyx and coils. The number of spring rings was 2-5 (average 2.55 + 0.91), and the volume range was 8.04 mm3 to 91.04 mm3 (average 32.15 + mm3), Onyx flat. All patients were successfully embolized by 2.57 + 0.86m1., of which 22 (88%) patients had complete embolization and 3 (12%) had nearly complete embolization. The 3 patients underwent cerebral angiography for 3 months after 3 months. All the other 22 patients had cerebral blood in 6 months after the operation. No recurrence was found in the tube. 7 (28%) patients were asymptomatic at discharge and 18 patients showed significant improvement in symptoms. All 25 cases were followed up from 6 to 49 months (median time was 10 months). In patients with improved symptoms, the clinical symptoms disappeared from 2 to 3 months after the operation. All patients were followed up. The end point remained asymptomatic. A total of 6 (24%) patients had complications,.1 patients showed contralateral eye force blurred, 1 patients had diplopia, 2 patients had temporary bradycardia during operation, 1 patients showed ipsilateral abducens paralysis, 1 patients showed ipsilateral eyelid edema. All the complications were cured. Conclusion effective application of On Embolization of cavernous sinus with YX and coils is the key to successfully cure the cavernous sinus dural arteriovenous fistula. The rational placement of the spring ring, the effective use of Onxy diffusely and well controlled characteristics, and the avoidance of excessive use of the coil and Onxy are useful ideas for effective cure of csDAVFs and reducing the incidence of complications. The second chapter is made by arterial approach Onyx embolization of the spongy dural arteriovenous fistula in the cavernous region of the cavernous region of the cavernous region of the cavernous sinus has become the most preferred choice for the treatment of the cavernous sinus through venous approach, although the occasional venous catheterization is difficult. The treatment of csDAVFs in our center via the cavernous sinus via venous embolization has also become a priority for the treatment of the disease. However, the frequently regulated subcutaneous sinus or superior ophthalmic venous catheterization occasionally fails. At this time, it is suggested that surgical intubation be performed to the superior ophthalmic vein or percutaneous transorbital catheterization into cavernous sinus, but this leads to many complications, such as orbital hematoma or infection, and injury to the adjacent cranial nerves. Some neurosurgeons pay for the use of the cortex. The vein, such as the superficial temporal vein and the superficial middle cerebral vein, is intubated into the cavernous sinus. However, exposing these cortical veins requires craniotomy and complicated procedures. The use of a liquid embolic agent to embolized the cavernous sinus dural arteriovenous fistula through the arterial pathway is a high risk for emboling the intermeningeal branches of the external carotid artery to the internal carotid artery. The risk of anastomosis, nerve trophoblast, ophthalmic artery, and vertebral artery. Because Onyx has the characteristics of good polymerization and low viscosity, it is helpful to control the permeability of the fistula, and has become the first choice for the treatment of dural arteriovenous fistula. There have been 3 cases that have been reported to try to use the Onyx through arterial pathway to embolized csDAVFs, Pero and so on. The use of Onyx to embolized csDAVFs in the pharynx artery (Onyx) case reports that 1 cases of the distal branch of the intra-maxillary artery with the Onyx embolic csDAVFs case.Amiridze described the case of the use of Onyx to embolic csDAVFs through the middle meningeal artery and the sphenopalatine artery. The main purpose of this article is to report the experience in the treatment of csDAVFs patients who were embolized via the arteriovenous Onyx via venous catheterization. Method and material 1. collection of clinical data and retrospective analysis of the failure of venous route therapy from November 2010 to 6 months of menstruation, and later to use arterial pathway Onyx to embolized the fistula. A detailed review of all clinical records, imaging data and operational records, missing data, history of previous treatment of intracranial diseases, and other patients with life expectancy diseases that may seriously affect the patient's life expectancy. All patients were classified by Borden-Shucart and Barrow classification methods, all of the csDAVFs patients were reviewed in detail. All patients were treated with conventional whole brain angiography under the femoral artery intubation under general anesthesia. Heparin maintained active coagulation time between 200 and 300 seconds. Cerebral angiography included bilateral selective internal carotid artery, external carotid artery angiography, and bilateral vertebral arteriography. The location of fistula, blood supply artery, and vein were confirmed. Drainage mode, collateral circulation, and dangerous vascular anastomosis. All patients were given priority for a trial intravenous embolization of cavernous sinus. For patients who had failed the venous catheterization, we used the transcatheter arterial embolization. A 6F guide tube was inserted into the external carotid artery and the contralateral femoral artery was inserted in the puncture intubation. A microcatheter is then placed in the distal position of a blood supply artery that is as close to the fistula as possible under the guidance of a micro guide wire. The best selective catheter tip wedge position is determined by ultra selective angiography to identify the normal arterial branches and the risk of anastomosis. The reflux stop reinjection is used under the real-time road map monitoring. "The technology is slowly injected with Onyx. when the glue is found back into the non target area, stopping injection for about 20 to 2 minutes to make Onyx precipitate and form an embolus around the head end of the catheter. Then reinjection to make Onyx diffuse into the entire fistula as far as possible without embolic risk kissing and the evaluation of important vascular.3. evaluation criteria. The criteria were: (1) complete embolization, no recognizable arteriovenous shunt; (2) subtotal embolism, only a small stagnant residual shunt without drainage of the cortical vein or the eye vein; (3) incomplete embolism, only the decrease of flow and obvious shunt remnants. Complete and subtotal embolism was considered to be a successful angiographic result. The criteria of evaluation were: (1) asymptomatic; (2) improvement, obvious improvement of the original symptoms; (3) no improvement, no change or aggravation of symptoms; (4) recurrence, new onset of symptoms in the follow-up period. Asymptomatic and symptomatic improvement was considered to be the clinical cure of.4. observation before the cerebral angiography of patients before embolization The cerebral vessels were made and the images of cerebral angiography were followed up to determine the therapeutic effect of imaging.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R743.3
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本文编号：2076666