颈动脉海绵窦瘘临床症状与引流静脉的关系及其致外展神经麻痹的影响因素分析

发布时间：2018-05-03 00:13

本文选题：颈动脉海绵窦瘘 + 临床症状　；参考：《南方医科大学》2014年硕士论文

【摘要】：研究背景：颈动脉海绵窦瘘(carotid cavernous fistula)最早由Baron在1835年报道,是指由颈内动脉海绵窦段或其分支破裂,导致颈内动脉与海绵窦之间形成异常动静脉交通的一组临床综合征,是一种少见的脑血管疾病。按发病原因,可分为外伤性和自发性,其中外伤性约占75%～85%,约占颅脑外伤的0.2-0.3%。外伤性颈动脉海绵窦瘘多发生于颅脑外伤时,颅底骨折导致骨折碎片直接刺破海绵窦段颈内动脉或其分支；自发性颈动脉海绵窦瘘则主要是指在没有外伤的情况下,由于遗传因素、动脉粥样硬化或海绵窦段动脉瘤破裂所致。 Santos等人报道颈动脉海绵窦瘘的临床表现与引流静脉密切相关。颈动脉海绵窦瘘的临床表现包括搏动性突眼、球结膜充血水肿、颅内血管杂音、眼球运动障碍、复视、上睑下垂、视力减退或丧失、头痛。部分患者还可能出现偏瘫、失语、抽搐、颅内出血、蛛网膜下腔出血、鼻出血等症状。发生颈动脉海绵窦瘘时,海绵窦部的静脉引流是多方向的,主要包括：向前引流至眼静脉,向后引流至岩上、下窦,向上引流至侧裂静脉或皮层静脉,向下引流至翼丛以及向内经海绵间窦引流至对侧海绵窦。Zeng等人对28例颈动脉海绵窦瘘患者的影像学资料进行分析,向前引流占89.3%,向后引流占85.7%,向上引流占21.4%,向下引流占49.5%,向对侧引流占4.1%。对颈动脉海绵窦瘘临床症状与引流静脉之间相互关系的充分认识,有助于提高该疾病的临床诊断率,同时对治疗方式的选择也可以提供重要帮助。目前,国内、外学者对颈动脉海绵窦瘘临床症状与引流静脉的研究多集中于病例报道及经验性总结,尚缺乏统计学研究。另外,海绵窦在解剖关系上与部分颅神经关系密切。海绵窦是全身唯一处静脉包绕动脉的特殊结构,在海绵窦内由于各种原因只要动脉或其分支破裂,即可形成动静脉之间的直接沟通。海绵窦位于颅中窝蝶鞍两旁,硬脑膜层与骨膜层之间,由多个分隔的静脉腔组成。海绵窦前至眶上裂,与视神经管和颈内动脉床突上段相邻；后达岩骨尖部,与颈内静脉和半月节相邻；内侧与蝶窦和垂体相邻；外侧为大脑颞叶、蝶骨、圆孔、卵圆孔相邻。海绵窦内有颈内动脉和脑神经通过,在前床突和后床突之间的海绵窦外侧壁的内层中,由上而下排列着动眼神经、滑车神经、眼神经和上颌神经。海绵窦腔内有颈内动脉和外展神经通过。外展神经起自展神经核,自延髓脑桥沟中部发出,穿过岩斜坡硬膜进入岩下窦开口下方的基底窦外下壁,在静脉窦内斜行向上走行5-8mm,穿过Gruber韧带形成的Dorello管,向前进入海绵窦后部。在窦内外展神经仍有硬膜包裹,与神经隔内筋膜融合,平行于颈内动脉水平部外壁,达眶上裂。Shownkeen、Vesna及国内的陈书扬等认为由于外展神经在颅内行程长,且途径海绵窦内部,颈动脉海绵窦瘘时,海绵窦的扩大及窦内压的升高,最易导致外展神经的麻痹,表现为外展受限,出现内斜视,影响患者的生活质量。但目前国内有关颈动脉海绵窦瘘致外展神经麻痹的研究较少,仅有相关的病例报道,尚缺乏对颈动脉海绵窦瘘致外展神经麻痹的影响因素的研究。目前,随着神经介入技术的发展,血管内介入治疗已成为治疗颈动脉海绵窦瘘的首选方案。其中可脱性球囊以简单、经济、有效的特点成为首选的栓塞材料。随着新型栓塞材料的出现及改进,弹簧圈、Onyx、NBCA、PVA颗粒及覆膜支架等亦逐渐用于颈动脉海绵窦瘘的治疗。对血管内栓塞治疗颈动脉海绵窦瘘的患者进行系统的临床随访总结,能够有效的评估栓塞效果及患者的预后,包括栓塞术后的复发及临床症状的恢复等。第一部分颈动脉海绵窦瘘的临床症状与引流静脉的关系及血管内栓塞治疗临床随访总结研究目的：归纳颈动脉海绵窦瘘的临床、影像学特点及其治疗方法,分析颈动脉海绵窦瘘临床症状与引流静脉之间的关系,探讨、总结颈动脉海绵窦瘘治疗、栓塞技术要点、并发症、复发原因及处理方法。研究方法：本文回顾性分析和总结南方医科大学珠江医院神经外科自2000年1月至2013年12月收治的具有完整病历资料的颈动脉海绵窦瘘病例156例。所有手术过程及操作均在全身肝素化及静脉麻醉下进行。采用Seldinger技术,经股动脉插管,先行全脑血管造影,全面了解瘘口的部位、数目、瘘口大小、静脉引流及脑循环状况等,再行血管内栓塞治疗。根据患者不同的引流静脉,采用x2检验分析其与各临床症状之间的关系。并对所有患者进行临床随访,随访方法：主要通过患者再次入院、门诊随访、部分电话访问、网络随访以及信件随访。随访内容以有无复发及临床症状恢复情况为主。统计资料全部采用SPSS18.0统计软件进行分析处理。研究结果：156例患者中男性99例,女性57例；年龄最大67岁,最小9岁,平均年龄(34.29±13.85)岁；治疗前症状持续时间在1周以内58例,1周到3周之间26例,3周到3个月之间47例,大于3个月25例；自发性颈动脉海绵窦瘘13例,创伤性颈动脉海绵窦瘘143例,包括车祸、跌落伤、锐器伤、斗殴、重物砸伤等；临床表现搏动性突眼140例,球结膜充血水肿150例,颅内血管杂音131例,眼球活动障碍92例,视力减退82例,复视19例,眼睑下垂26例,头痛39例,鼻出血2例,颅内出血1例；有伴随症状75例；22例患者栓塞术后出现并发症,其中头痛10例,颅神经一过性麻痹7例,脑血管痉挛2例,穿刺部位血肿2例,鼻出血1例。156例患者中,复杂性、难治性颈动脉海绵窦瘘18例。颈动脉海绵窦瘘的静脉引流是多方向的：向前引流至眼静脉148例,向后引流至岩上、下窦125例,向上主要引流至侧裂静脉及皮层静脉19例,向下引流至翼丛74例。向前引流可能与搏动性突眼(x2=54.661,P=0.000)、颅内血管杂音(x2=7.233,P=0.007)球结膜充血水肿(x2=25.824,P=0.000)、视力减退(x2=5.428,P=0.020)有关；向后引流可能与颅内血管杂音(x2=4.675,P=0.031)、眼球运动障碍(x2=14.336,P=0.000)有关；向上引流可能与头痛(x2=12.630,P=0.000)有关。 156例患者中148例采用血管内栓塞治疗,其中可脱性球囊栓塞133例,弹簧圈栓塞5例,两者联合栓塞4例,弹簧圈联合Onyx栓塞4例,球囊联合PVA颗粒栓塞2例。栓塞过程中有15例行颈内动脉闭塞,颈内动脉通畅率为89.9%。栓塞治疗术后有22例出现并发症,发生率14.9%。对148例患者进行随访,获得随访116例,随访率78.4%。随访时间为3个月-2年,平均随访18个月。12例患者予第一次栓塞后出现复发,复发率8.1%。其中男性7例,女性5例。4例单球囊栓塞后复发,7例多球囊栓塞后复发,1例弹簧圈栓塞后复发。复发时间为术后ld-65d,平均17天,其中1周内复发8例。复发的12例患者中6例采用可脱性球囊再次栓塞后治愈,3例采用弹簧圈栓塞瘘口,1例行颈内动脉闭塞,1例予保守压颈治疗后痊愈,1例家属拒绝治疗。颅内血管杂音手术后立即消失108例,占95.6%；搏动性突眼2周内恢复99例,占93.4%；球结膜充血水肿113例,2周内恢复105例,占92.3%。神经功能受损所致眼球运动障碍半年内恢复或有所好转61例,占81.3%；眼睑下垂患者中17例1年内恢复正常,占85%。研究结论：(1)颈动脉海绵窦瘘的临床表现与引流静脉关系密切：向前引流可能与搏动性突眼、颅内血管杂音、球结膜充血水肿、视力减退有关；向后引流可能与颅内血管杂音、眼球运动障碍有关；向上引流可能与头痛、颅内出血或蛛网膜下腔出血有关。 (2)可脱性球囊栓塞颈动脉海绵窦瘘由于球囊泄气、移位、造影剂外渗等仍存在一定的复发,但复发率低,且多于栓塞后1周复发。 (3)颈动脉海绵窦瘘的预后较好,多数临床症状在短期内恢复,但神经功能受损引起的眼部症状恢复较慢,需要6个月～12个月左右时间。第二部分颈动脉海绵窦瘘致外展神经麻痹的影响因素的分析研究目的：颈动脉海绵窦瘘患者中动眼神经、滑车神经、外展神经经常受累,导致眼球运动障碍,严重影响患者的预后及生活质量。其中外展神经由于特殊的解剖位置,最易受累,引起患者眼球外展受限。本文拟对颈动脉海绵窦瘘致外展神经麻痹的影响因素进行分析,以便临床医生能够充分认识并重视颈动脉海绵窦瘘患者神经功能的受损,并有效预防及判断其预后。研究材料和方法：回顾性分析和总结南方医科大学珠江医院神经外科自2000年1月至2013年12月收治的具有完整病历资料的颈动脉海绵窦瘘病例156例,所有的患者均行全脑血管造影术,在全身肝素化及静脉麻醉下,采用Seldinger技术,经股动脉或股静脉插管,先行全脑血管造影,全面了解瘘口的部位、数目、瘘口部血流量、静脉引流方向及脑循环状况等,再采用可脱性球囊或弹簧圈行血管内栓塞治疗。将156例患者分为外展神经麻痹组和外展神经非麻痹组,应用单因素分析及二分类多因素Logistic回归分析探讨性别、年龄、发病原因、治疗前症状持续时间、有无合并颅底骨折或颅高压、瘘口侧别、瘘口血流量、瘘口数目、有无盗血及引流静脉等因素对外展神经麻痹发生的影响。全部数据采用SPSS18.0统计软件处理。研究结果：156例颈动脉海绵窦瘘患者中外展神经麻痹组74例,外展神经非麻痹组82例。单因素分析结果显示：治疗前症状持续时间长(x2=4.849,P=0.028)、合并颅底骨折或颅高压(x2=4.249,P=0.028)、瘘口血流量大(x2=4.148,P=0.042)及经岩上、下窦引流(x2=7.259,P=0.007)是导致外展神经麻痹的4个影响因素。Logistic回归分析显示：治疗前症状持续时间长(R=3.074,95%CI：1.492～6.333)、合并颅底骨折或颅高压(R=2.152,95%CI：1.090-4.248)、瘘口血流量大(R=2.736,95%CI：1.261-5.423)及经岩上、下窦引流(R=5.075,95%CI：1.933-13.326)是导致外展神经麻痹的4个独立影响因素,其中经岩上、下窦引流是最主要的影响因素。研究结论：颈动脉海绵窦瘘引起外展神经麻痹的因素是多方面的,其中经岩上、下窦引流是最主要的影响因素。
[Abstract]:Background of Study :

Carotid cavernous fistula ( carotid cavernous fistula ) , which was first reported by the department of carotid cavernous fistula , is a group of clinical syndromes of abnormal arteriovenous transportation between internal carotid artery and cavernous sinus due to the rupture of cavernous sinus segment of internal carotid artery or its branches , which is a rare cerebrovascular disease .
Spontaneous carotid cavernous fistula mainly refers to the absence of trauma , due to genetic factors , atherosclerosis , or rupture of the cavernous sinus segment .

The clinical manifestation of cavernous fistula of carotid artery is closely related to drainage vein . The clinical manifestations of cavernous fistula of carotid artery include pulsatile ophthalmos , conjunctival congestion edema , intracranial vascular murmur , eye movement disorder , diplopia , ptosis , intracranial hemorrhage , subarachnoid hemorrhage , nasal hemorrhage , etc .

in addition , that cavernous sinus is closely related to a part of the cranial nerve in the anatomical relationship , the cavernous sinus is the unique structure of the whole body of the vein around the whole body , and the cavernous sinus can form a direct communication between the arteriovenous fistula due to various reasons as long as the artery or its branches are broken .
the back reaches the tip of the rock bone , and is adjacent to the internal jugular vein and the half - moon section ;
the inner side is adjacent to the sinus and the pituitary ;
The outer side is the temporal lobe of the brain , the butterfly bone , the round hole and the oval round hole . Inside the cavernous sinus , the internal carotid artery and the cranial nerves pass through , and the inner layer of the outer wall of the cavernous sinus between the front bed process and the back bed process is arranged with the motor - eye nerve , the trocars , the eyes and the nerves through the internal layer of the outer wall of the cavernous sinus between the front bed process and the posterior bed process .

The outer abducens of the cavernous sinus and the cavernous sinus of the cavernous sinus of the cavernous sinus in the cavernous sinus of the cavernous sinus and the internal carotid artery of the cavernous sinus in the cavernous sinus . The results show that the external abducens nerve is in the middle of the cavernous sinus .

At present , with the development of interventional technique , endovascular interventional therapy has become the preferred embolization material for carotid cavernous fistula . With the advent and improvement of new embolic material , coil , Onyx , NBCA , PVA particles and stent graft have been gradually used in the treatment of carotid cavernous fistula .

The relationship between the clinical symptoms and drainage vein in the first part of carotid cavernous fistula and the clinical follow - up of endovascular embolization

Objective : To summarize the clinical , imaging features and therapeutic methods of carotid cavernous fistula , analyze the relationship between clinical symptoms and drainage vein of carotid cavernous fistula , discuss the main points , complications , recurrence cause and treatment methods of carotid cavernous fistula treatment and embolization .

Methods : 156 cases of carotid cavernous fistula with complete medical record data from January 2000 to December 2013 were retrospectively analyzed and summarized . All operating procedures and operations were performed under general heparinization and vein anaesthesia .

Methods : The patients were hospitalized again , followed by outpatient follow - up , some telephone interviews , network follow - up and correspondence follow - up . The follow - up was mainly based on whether there were recurrence and clinical symptoms . All statistical data were analyzed by SPSS 18.0 .

Results : There were 99 males and 57 females in 156 patients .
The age was 67 years , the youngest was 9 years , the mean age ( 34.29 卤 13.85 ) years ;
The duration of pre - treatment symptoms was 58 cases within 1 week , 26 between 1 week and 3 weeks , 47 cases between 3 weeks and 3 months , more than 3 months 25 cases ;
There were 13 cases of spontaneous carotid cavernous fistula , 143 cases of traumatic carotid cavernous fistula , including car accident , falling injury , sharp injury , fight , heavy weight injury , etc .
There were 140 cases with clinical manifestation , 150 cases of bulbar conjunctival congestion , 131 cases of intracranial vascular murmur , 92 cases of eyeball movement disorder , 82 cases with visual loss , 19 cases of diplopia , 26 cases of ptosis , 39 cases of headache , 2 cases of nasal hemorrhage and 1 case of intracranial hemorrhage .
There were 75 cases with concomitant symptoms .
Complications occurred in 22 patients , including 10 cases of headache , 7 cases of cranial nerve paralysis , 2 cases of cerebrovascular spasm , 2 cases of hematoma in puncture site and 1 case of nasal hemorrhage .

The venous drainage of cavernous fistula of carotid artery was multi - direction : 148 cases of anterior drainage to the eye vein , 125 cases of inferior sinus , and 19 cases of lateral fissure vein and cortical vein .
The posterior drainage may be related to intracranial vessel murmur ( x2 = 4.675 , P = 0.031 ) , and eye movement disorder ( x2 = 14.336 , P = 0.000 ) ;
The upward drainage may be associated with headache ( x2 = 12.630 , P = 0.000 ) .

Of the 156 patients , 148 patients were treated with endovascular embolization , of which the detachable balloon was embolized in 133 cases , the coil was embolized in 5 cases , the two were embolized in 4 cases , the coils were embolized with Onyx in 4 cases , the average follow - up rate was 89.9 % . The follow - up time was 3 months - 2 years . The follow - up rate was 89.9 % . The follow - up time was 3 months - 2 years .
99 cases were recovered within 2 weeks of pulsatile ophthalmos , accounting for 93.4 % ;
There were 113 cases of bulbar conjunctival congestion , 105 cases recovered in 2 weeks , 92.3 % , 61 cases recovered or improved in half a year due to nerve function damage , accounting for 81.3 % ;
17 of the patients with eyelid ptosis recovered to normal after 1 year , accounting for 85 % .

Conclusions : ( 1 ) The clinical manifestation of carotid cavernous fistula is closely related to drainage vein : forward drainage may be related to pulsatile process , intracranial vascular murmur , conjunctival congestion and edema , and visual deterioration ;
The posterior drainage may be associated with intracranial vascular murmur , ocular movement disorders ;
The upward drainage may be associated with headache , intracranial hemorrhage or subarachnoid hemorrhage .

( 2 ) There were some recurrence of carotid cavernous fistula due to balloon leakage , displacement and extravasation of contrast agent , but the recurrence rate was low , and the recurrence of carotid cavernous fistula was more than 1 week after embolization .

( 3 ) The prognosis of carotid cavernous fistula is good , most clinical symptoms are recovered in the short term , but the recovery of ocular symptoms caused by nerve function damage is slow , which takes 6 months to 12 months .

Analysis of the influencing factors of external abducent nerve paralysis caused by cavernous fistula of carotid cavernous sinus in the second part

Objective : To study the influence factors of carotid cavernous fistula on the nerve function of patients with carotid cavernous fistula , and to prevent and judge the prognosis of carotid cavernous fistula .

Materials and Methods : 156 cases of carotid cavernous fistula with complete medical record data from January 2000 to December 2013 were retrospectively analyzed and summarized .

Results : Of the 156 cases of carotid cavernous fistula , there were 74 cases of external abducens nerve paralysis and 82 cases of abducens nerve paralysis . The results of single factor analysis showed that the duration of pre - treatment symptoms was long ( x2 = 4.849 , P = 0.028 ) , the blood flow of fistula was large ( x2 = 4.148 , P = 0.042 ) , and the drainage of inferior sinus ( R = 2.736 , 95 % CI : 1.933 - 13.326 ) was the four independent factors leading to abducens nerve paralysis .

It is concluded that the factors that cause the paralysis of external abducens nerve caused by cavernous fistula of carotid artery are manifold , among which the drainage of inferior sinus is the most important factor .

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743

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