硬脑膜动静脉瘘预后因素分析及血管内治疗的临床研究

发布时间：2018-05-01 07:07

本文选题：硬脑膜动静脉瘘 + 临床特征　；参考：《浙江大学》2015年博士论文

【摘要】：第一章硬脑膜动静脉瘘预后因素分析研究背景DAVF为硬脑膜动脉与皮层静脉或静脉窦的异常交通,其临床特征各异。不同部位的DAVF在临床症状、影像学表现、血管构筑、治疗方式与预后上各有不同。多数DAVF的自然病程为良性,然而一旦发生颅内出血,预后多不佳。然而,由于DAVF的高度异质性,目前尚无预测DAVF预后的相关模型。DAVF的临床特点、影像特征治疗方式与其预后的关系有待进一步探究。目的统计DAVF的临床特点、影像学特征、治疗方式及预后资料,探究DAVF预后的相关因素。方法本组病例为2010年至2015年浙江大学医学院附属第二医院诊疗的79例DAVF患者,其中男性52例,女性27例,平均年龄52.2岁。收集这些病例的临床症状、DAVF位置、Cognard分型、供应血管、治疗方式、治疗结果、随访mRS评分等。根据随访mRS评分将患者分为预后良好与预后不佳两组,对上述的临床特点,行Kruskal-Wallis单因素稳健方差分析与Logistic多因素回归分析,探究DAVF预后的相关因素。结果本组中自发性DAVF有70例(88.6%)。临床症状中头痛共41人次(51.9%),海绵窦症状32人次(40.5%),颅内出血与NHND各13人次(16.5%)。海绵窦DAVF共31例(41.3%),横窦乙状窦DAVF共18例(24%),直窦DAVF共12例(16%),前颅底DAVF共9例(12%),上矢状窦(6.7%)。Cognard分型低级别DAVF共20例(25.3%),包括Cognard Ⅰ型4例,Cognard Ⅱa型16例;高级别DAVF共60例,包括CognardⅡb型19例(24.1%),Cognard Ⅱa+Ⅱb型10例(12.7%),Cognard III型11例(13.9%),Cognard IV型19例(24.1%)以及Cognard V型1例(1.3%)。本组中采用TAE的有53例(67.1%),手术治疗13例(16.5%),TVE治疗12例(15.2%),放射治疗1例(1.3%)。总治愈率为55.7%,其中手术治疗的13例DAVF均达完全栓塞;TAE中22例达完全栓塞,完全栓塞率为41.5%；TVE中9例达完全栓塞,完全栓塞率率为75%。本组平均随访31.1月,随访时mRS平均分2.1士1.3,分其中预后良好(mRS≤2)43人,预后不佳(mRS2)19人。单因素Kruskal-Wallis检验提示初始症状在DAVF预后上有显著的差异。颅内出血为首发症状的患者,其mRS评分显著高于以头痛或搏动性杂音为首发症状的患者。其他症状间的mRS评分无显著差异。随访时症状无改善的病人,其mRS评分也要显著高于随访时症状消失的病人。Logistic多因素检验提示随访时症状无改善是预后不良的相关因素,未发现其他与预后显著相关的因素。结论 (1)本组79例病人,平均年龄52.2±11.1岁,男性偏多,自发性DAVF常见。 (2)本组中头痛为最常见的临床症状,其次为海绵窦相关症状。海绵窦与横窦乙状窦为DAVF最高发的区域。女性DAVF多发于海绵窦,性别在DAVF发病位置上差异显著。 (3) DAVF的位置与临床症状、Cognard分型、治疗方式相关。前颅底DAVF多选择手术治疗,TVE用于海绵窦与横窦乙状窦DAVF,TAE对于各个位置的DAVF均有使用。 (4)单因素分析中,颅内出血是DAVF预后不良的相关因素。Logistic多因素分析下,除随访症状与DAVF预后相关外,未发现其他预后相关因素。对出血高风险的患者,在颅内出血事件发生前及时治疗仍能获得良好预后。第二章硬脑膜动静脉瘘的血管内治疗研究背景DAVF的治疗方法很多,包括保守观察、手术治疗、放射治疗与血管内治疗。血管内治疗因其直接到达患处被认为是DAVF最理想的治疗方式。TVE一直被认为是最安全可靠的血管内治疗途径,TAE因不良事件严重与操作困难,一直难以推广。但随着介入技术的不断发展,新型栓塞材料Onyx胶的发明提高了TAE的完全栓塞率与安全性。TAE对于治疗DAVF的适用性、安全性与治疗效果仍存争议。目的统计TAE与TVE治疗DAVF的适用范围、完全栓塞率、不良反应与预后,评估TAE与TVE在治疗DAVF上的作用。方法本组回顾性病例对照研究。资料为2010年至2015年浙江大学医学院附属第二医院行血管内治疗并完成随访的46例DAVF患者,分为TAE治疗组与TVE治疗组,以DAVF的解剖部位、Cognard分级、完全栓塞率、并发症及随访mRS评分为因变量。统计上述变量在不同血管内治疗途径上的差异,以评估TAE与TVE在治疗DAVF上的作用。结果本组血管内治疗患者46例,采用TAE36例,TVE10例,总体完全栓塞率52.2%,TAE组完全栓塞率44.4%,TVE组完全栓塞率为80%,两组间差异显著(p=0.038)。TAE组中18例位于海绵窦,9例位于横窦与乙状窦,6例位于直窦,2例位于上矢状窦,1例位于前颅底,相应完全栓塞率为38.9%,44.4%,50%,50%,100%。TVE组中5例位于海绵窦,3例位于横窦与乙状窦,2例位于直窦,前颅底与上矢状窦无采用TVE治疗。 TAE组中26例采用Onyx胶,8例采用n-BCA胶,2例采用弹簧圈填塞。TVE治疗组中8例采用弹簧圈,1例采用Onyx胶,1例同时采用了弹簧圈与Onyx胶。TAE组中n-BCA胶完全栓塞率为50%,Onyx胶完全栓塞率42.3%,次全栓塞率23.1%,弹簧圈的完全栓塞率为50%。TVE组中弹簧圈的完全栓塞率为77.8%,次全栓塞为22.3%。TAE组患者随访时平均mRS为2.03±1.21,TVE组随访时平均mRS为0.80±1.06。两组间患者随访时的mRS评分无显著差异。TAE组术后出现1例患者右眼视力进一步减退,1例患者动眼神经麻痹,TVE组术后1例自觉头痛加重,无其他手术并发症。结论 (1)本组中TVE的完全栓塞率显著高于TAE。 (2)TAE用于位于海绵窦、前颅底、横窦乙状窦、直窦、矢状窦的DAVF, TVE不用于前颅底与上矢状窦的DAVF。TVE不用于Cognard Ⅲ型以上的DAVF。 (3)TAE与TVE两组间随访mRS评分无显著差异。TAE与TVE均较少发生术后并发症,TAE与TVE在治疗DAVF中都是安全有效的。 (4)TAE较TVE有更高的性价比。随着Onyx的应用与TAE技术的成熟,TAE在我国等发展中国家不失为可推广的DAVF治疗方法。
[Abstract]:Analysis of prognostic factors of dural arteriovenous fistula in the first chapter
Background DAVF is the abnormal traffic of the dura mater artery and the cortical vein or venous sinus. The clinical features of the DAVF are different in the clinical symptoms, imaging manifestations, vascular architecture, treatment and prognosis. Most of the natural course of DAVF is benign, however, the prognosis of the intracranial hemorrhage is mostly poor. However, because of DAVF At present, there is no correlation model of DAVF prognosis. The clinical characteristics of.DAVF, the relationship between the imaging modalities and the prognosis need to be further explored.
Objective to investigate the clinical characteristics, imaging features, treatment modalities and prognosis of DAVF, and to explore the prognostic factors of DAVF.
Methods 79 DAVF patients were diagnosed and treated in Second Affiliated Hospital of Zhejiang University Medical College from 2010 to 2015, including 52 males and 27 females, with an average age of 52.2 years. The clinical symptoms, DAVF position, Cognard typing, supply of blood vessels, treatment, treatment results and follow-up mRS score were collected. The patients were followed up with mRS score. The two groups were divided into two groups with good prognosis and poor prognosis. On the basis of the above clinical characteristics, the Kruskal-Wallis single factor robust variance analysis and Logistic multiple regression analysis were used to explore the related factors of the prognosis of DAVF.
Results there were 70 cases (88.6%) of spontaneous DAVF in this group. There were 41 headaches (51.9%), 32 cavernous sinus symptoms (40.5%), intracranial hemorrhage and NHND 13 person times (16.5%), 31 cavernous sinus DAVF (41.3%), 18 (24%) in transverse sinus sigmoid sinus (24%), DAVF in anterior skull base and.Cognard classification of superior sagittal sinus. A total of 20 cases (25.3%) of low grade DAVF, including 4 cases of Cognard I, 16 cases of Cognard II A, 60 cases of high grade DAVF, including 19 cases of Cognard II B (24.1%), 10 cases of a+ II B type II (12.7%), 11 cases of Cognard III (13.9%), Cognard IV 19 cases (24.1%) and Cognard type 1. 16.5%) TVE treatment in 12 cases (15.2%), 1 cases (1.3%) with total cure rate of 55.7%, of which 13 cases of DAVF were completely embolized; 22 cases in TAE were completely embolized and the total embolism rate was 41.5%; 9 cases in TVE were completely embolized and the rate of complete embolism rate was 75%. in the average follow-up period of 31.1 months, and the prognosis was divided into 2.1 1.3 in the follow-up. Among them the prognosis was divided among them the prognosis. Good (mRS < 2) was 43, and the prognosis was poor (mRS2) 19.
The single factor Kruskal-Wallis test suggested that the initial symptoms were significantly different in the prognosis of DAVF. The mRS score of the patients with intracranial hemorrhage as the first symptom was significantly higher than that of the first symptom with headache or pulsating murmur. There was no significant difference in the mRS score between the other symptoms. The mRS score of the patients with no improvement in the follow-up was significantly higher. .Logistic multifactor test in patients with disappearance of symptoms at follow-up showed that no improvement in symptoms was associated with poor prognosis during follow-up, and other factors associated with prognosis were not found.
conclusion
(1) the average age of 79 patients in this group was 52.2 + 11.1 years, and the number of male patients was more than that of spontaneous DAVF.
(2) headache is the most common clinical symptom in this group, followed by cavernous sinus related symptoms. Cavernous sinus and transverse sinus sigmoid sinus are the highest DAVF areas. Female DAVF frequently occurs in cavernous sinus, and sex is significantly different in the position of DAVF.
(3) the location of DAVF is related to clinical symptoms, Cognard typing, and treatment. Anterior skull base DAVF is selected for surgical treatment, TVE is used in cavernous sinus and transverse sinus sigmoid DAVF, and TAE is used for DAVF in all locations.
(4) in single factor analysis, intracerebral hemorrhage is the correlation factor of poor prognosis of DAVF,.Logistic multifactor analysis. Except the follow-up symptoms and the prognosis of DAVF, no other prognostic factors are found.
Intravascular treatment of dural arteriovenous fistula in the second chapter
Background DAVF has many treatments, including conservative observation, surgical treatment, radiation therapy and intravascular therapy. Intravascular therapy because of its direct access to the affected area is considered the most ideal treatment for DAVF,.TVE has been considered as the safest and reliable intravascular therapy, and TAE has been difficult to push due to severe adverse events and difficult operation. However, with the continuous development of interventional technology, the invention of new embolic material Onyx glue improves the complete embolization rate and safety of TAE,.TAE is still controversial for the applicability of the treatment of DAVF, and the safety and therapeutic effect.
Objective to evaluate the applicability of TAE and TVE in the treatment of DAVF, the complete embolization rate, adverse reactions and prognosis, and evaluate the role of TAE and TVE in the treatment of DAVF.
Methods a retrospective case control study was conducted. The data were divided into the TAE treatment group and the TVE treatment group in the Second Affiliated Hospital of the Second Affiliated Hospital of Zhejiang University from 2010 to 2015, divided into the TAE treatment group and the TVE treatment group, with the anatomical site of the DAVF, the Cognard classification, the complete embolism rate, the complication and the follow-up mRS score as the dependent variable. The difference between the amount of treatment in different intravascular approaches is to evaluate the role of TAE and TVE in the treatment of DAVF.
Results 46 cases of intravascular therapy, TAE36 cases, TVE10 cases, total total embolism rate 52.2%, group TAE complete embolism rate 44.4%, group TVE complete embolism rate of 80%, 18 cases in the two group (p=0.038) 18 cases in the cavernous sinus, 9 cases in the transverse sinus and sigmoid sinus, 6 cases in the straight sinus, 2 cases in the superior sagittal sinus, 1 cases of the anterior skull base, and 1 cases in the anterior skull base. The rate of complete embolization was 38.9%, 44.4%, 50%, 50%. 5 cases in the group 100%.TVE were located in the cavernous sinus, 3 in the transverse sinus and the sigmoid sinus, 2 in the straight sinus, and the anterior skull base and the superior sagittal sinus were not treated with TVE.
In group TAE, 26 cases were treated with Onyx glue, 8 with n-BCA glue, 2 with spring coil filling in.TVE treatment group, 8 with spring coil, 1 with Onyx glue, 1 with the complete embolism rate of n-BCA glue in the spring ring and Onyx glue.TAE group at 50%, the Onyx glue complete embolism rate 42.3%, the subtotal embolus rate 23.1%, and the complete embolism rate of the coil ring in the 50%.TVE group. The complete embolic rate of the reed circle was 77.8%, and the average mRS was 2.03 + 1.21 in the 22.3%.TAE group. The average mRS in group TVE was 0.80 + 1.06. two groups. There was no significant difference in the mRS score in the follow up group. The visual acuity of the right eye was further reduced in the 1 patients after the operation in the group.TAE, 1 cases of the oculomotor paralysis, and 1 of the TVE group after operation. The pain was aggravated and there were no other complications.
conclusion
(1) the total embolism rate of TVE in this group was significantly higher than that of TAE.
(2) TAE is used in the cavernous sinus, the anterior skull base, the transverse sinus sigmoid sinus, the straight sinus, the sagittal sinus and the DAVF, and the TVE not used in the anterior skull base and the superior sagittal sinus DAVF.TVE is not used for the DAVF. above Cognard type III
(3) there was no significant difference in follow-up mRS score between the two groups of TAE and TVE..TAE and TVE all had less postoperative complications. TAE and TVE were safe and effective in the treatment of DAVF.
(4) TAE has a higher cost performance than TVE. With the application of Onyx and the maturity of TAE technology, TAE is a popular DAVF treatment method in developing countries such as China.

【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R651.1

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