本文選題：硬腦膜動(dòng)靜脈瘺 + 海綿竇　； 參考：《南方醫(yī)科大學(xué)》2015年博士論文

【摘要】：顱內(nèi)硬腦膜動(dòng)靜脈瘺(dural arteriovenous fistulas, DAVFs)占顱內(nèi)動(dòng)靜脈畸形的10%-15%。DAVFs可發(fā)生于硬膜及其附件的任何部位。海綿竇區(qū)硬腦膜是最常見(jiàn)的發(fā)生部位之一。海綿竇區(qū)硬腦膜動(dòng)靜脈瘺(Cavernous sinus dural arteriovenous fistulas, csDAVFs)常有許多起源于頸內(nèi)動(dòng)脈或頸外動(dòng)脈細(xì)小的供血?jiǎng)用},并且常累及雙側(cè)海綿竇,因此通過(guò)外科手術(shù)切除較為困難。而放射治療起效的時(shí)間過(guò)長(zhǎng)且療效不確切,因此不適宜作為一線治療方式。血管內(nèi)治療已發(fā)展成為治療csDAVFs的首要的治療策略。Onyx液體栓塞系統(tǒng)是近年來(lái)出現(xiàn)的栓塞劑,具有彌散性能好、低黏性且聚合較慢的特點(diǎn)。所有這些性質(zhì)使得Onyx允許更長(zhǎng)時(shí)間的注射及更好的控制能力。與其它栓塞劑對(duì)比,現(xiàn)在Onyx已更頻繁地用來(lái)治療DAVFs。但目前臨床上對(duì)csDAVFs的治療不規(guī)范,有些病例存在治療困難。因此將本文重點(diǎn)探討在應(yīng)用Onyx的背景下如何有效地應(yīng)用血管內(nèi)介入栓塞的方法治療csDAVFs。第一章有效地應(yīng)用彈簧圈聯(lián)合Onyx栓塞海綿竇治療海綿竇區(qū)硬腦膜動(dòng)靜脈瘺研究背景和目的應(yīng)用Onyx聯(lián)合彈簧圈經(jīng)靜脈入路栓塞海綿竇以治療csDAVFs已成為該病首選的治療方法,但是常常由于手術(shù)操作相關(guān)的并發(fā)癥較多,比如不全栓塞致顱內(nèi)出血,海綿竇內(nèi)或海綿竇壁內(nèi)顱神經(jīng)受刺激導(dǎo)致相應(yīng)的并發(fā)癥,術(shù)中出現(xiàn)心率下降甚至心跳停跳的問(wèn)題等。這些都是應(yīng)該在治療中該注意及解決的問(wèn)題。因此本文將結(jié)合我們的病例,總結(jié)我們的治療經(jīng)驗(yàn),介紹如何有效地應(yīng)用Onyx聯(lián)合彈簧圈栓塞海綿竇以治療csDAVFs。方法與材料1.收集臨床資料回顧性分析自2008年8月至2013年2月使用Onyx或聯(lián)合彈簧圈經(jīng)巖下竇入路栓塞海綿竇治療csDAVFs的病人資料。詳細(xì)回顧全部的臨床記錄、影像學(xué)資料及操作記錄。排除資料缺失、既往有顱內(nèi)疾病治療史及患有其他可能?chē)?yán)重影響患者的預(yù)期壽命疾病的病人。所有病人均按Borden-Shucart分類(lèi)及Barrow分類(lèi)方法進(jìn)行分型。2.治療方法所有患者住院期間均接受經(jīng)股動(dòng)脈腦血管造影檢查,術(shù)中持續(xù)給予肝素以保持每個(gè)病人的活化凝血時(shí)間在200s至300s間。造影包括雙側(cè)頸內(nèi)動(dòng)脈、雙側(cè)頸外動(dòng)脈及椎動(dòng)脈造影,以確認(rèn)瘺口的位置、供血?jiǎng)用}及引流靜脈等信息。所有病人均經(jīng)股靜脈-巖下竇入路進(jìn)行栓塞。我們將一根6F指引導(dǎo)管置入頸內(nèi)靜脈內(nèi),利用一根微導(dǎo)管在微導(dǎo)絲的輔助下經(jīng)過(guò)同側(cè)或?qū)?cè)巖下竇進(jìn)入海綿竇內(nèi)。將一根5F診斷性造影導(dǎo)管放置在頸外動(dòng)脈或頸內(nèi)動(dòng)脈內(nèi),利用路圖技術(shù)標(biāo)出靶點(diǎn)位置。首先,我們?cè)u(píng)價(jià)血流動(dòng)脈學(xué)的特點(diǎn),若在動(dòng)脈期或毛細(xì)血管期存在逆向充盈的引流靜脈,則將部分彈簧圈放置在引流靜脈的出口附近,在注射Onyx前將微導(dǎo)管的頭端置入彈簧圈的網(wǎng)眼中。溶度為6%的Onyx(18)在監(jiān)視下被緩慢注入海綿竇內(nèi)。如果Onyx彌散入非目標(biāo)區(qū),我們就停止注射約20秒至2分鐘,試圖讓Onyx產(chǎn)生聚合作用以達(dá)到改變彌散方向的目的,我們也會(huì)調(diào)整微導(dǎo)管頭端的位置以使Onyx達(dá)至更好的彌散效果。我們的目標(biāo)是使Onyx成功地彌散入海綿竇的每個(gè)部分。3.評(píng)價(jià)標(biāo)準(zhǔn)影像學(xué)的評(píng)價(jià)標(biāo)準(zhǔn)為：(1)完全栓塞,沒(méi)有可以辨認(rèn)的動(dòng)靜脈分流；(2)次全栓塞,只有小的停滯不前的殘存分流而無(wú)皮層靜脈或眼靜脈的引流；(3)不完全栓塞,只有流量的減少而有明顯的分流殘存。完全及次全栓塞被認(rèn)為是成功的血管造影結(jié)果。臨床的評(píng)價(jià)標(biāo)準(zhǔn)為：(1)無(wú)癥狀；(2)改善,原有癥狀的明顯改善；(3)無(wú)改善,癥狀無(wú)改變或加重；(4)復(fù)發(fā),隨訪期新發(fā)的與病變相關(guān)的癥狀。無(wú)癥狀及癥狀明顯改善被認(rèn)為是臨床治愈。4.觀察方法對(duì)比患者栓塞前的腦血管造影的影像資料、術(shù)后即刻腦血管造影影像資料、及隨訪腦血管造影的影像資料,以確定影像學(xué)的治療效果。觀察患者出院時(shí)及隨訪期的臨床癥狀與體征,與入院時(shí)的臨床癥狀與體征對(duì)比,以確定臨床治療效果。觀察并發(fā)癥的轉(zhuǎn)歸情況。5.統(tǒng)計(jì)學(xué)方法利用SPSS 19.0統(tǒng)計(jì)軟件進(jìn)行分析。平均年齡、平均Onyx使用量、平均彈簧圈使用數(shù)量及體積采用算數(shù)平均數(shù)表示,平均臨床隨訪期采用中位數(shù)表示。結(jié)果共收集到25個(gè)資料完整的病人,包括14個(gè)女性,11個(gè)男性,年齡從16歲至70歲(平均46.88±13.28歲)。根據(jù)Barrow分型,1個(gè)病人屬于C型,24個(gè)病人屬D型。根據(jù)B orden分型,20個(gè)病人屬于I型,5個(gè)病人屬于II型。11例累及左側(cè)海綿竇,8例累及右側(cè)海綿竇,6例累及雙側(cè)海綿竇。所有病人均有結(jié)膜充血(100%,25/25),24個(gè)病人有突眼(96.0%,24/25),17個(gè)病人有球結(jié)膜水腫(68.0%,n=17)。共實(shí)施了25個(gè)栓塞程序。共有3個(gè)病人單用Onyx,其余22個(gè)病人使用Onyx及彈簧圈。使用彈簧圈的數(shù)量為2-5個(gè)(平均2.55±0.91個(gè)),體積范圍為8.04 mm3至91.04 mm3 (平均32.15±16.03 mm3), Onyx平均使用量為2.57±0.86m1。術(shù)后即刻造影顯示所有病人取得了成功栓塞,其中,22(88.0%)個(gè)病人取得了完全栓塞,3(12.0%)病人取得了近完全栓塞。該3個(gè)病人術(shù)后3個(gè)月行腦血管造影復(fù)查,均發(fā)現(xiàn)取得了完全栓塞。其余的22個(gè)病人,術(shù)后6個(gè)月的腦血管造影未發(fā)現(xiàn)復(fù)發(fā)。出院時(shí)7(28.0%)個(gè)病人表現(xiàn)出無(wú)癥狀,余18個(gè)病人表現(xiàn)為癥狀明顯改善。所有25個(gè)病例,臨床隨訪間期為6至49個(gè)月(中位數(shù)時(shí)間為10個(gè)月)。在取得癥狀改善的病人中,臨床癥狀在術(shù)后2周至3個(gè)月內(nèi)逐漸消失。所有病人在隨訪終點(diǎn)均保持無(wú)癥狀。共6(24.0%)個(gè)病人發(fā)生并發(fā)癥。1個(gè)病人表現(xiàn)為對(duì)側(cè)眼力模糊,1個(gè)病人為復(fù)視加重,2個(gè)病人術(shù)中發(fā)生暫時(shí)性的心動(dòng)過(guò)緩,1個(gè)病人表現(xiàn)為同側(cè)展神經(jīng)麻痹,1個(gè)病人表現(xiàn)為同側(cè)眼瞼水腫。所有并發(fā)癥均治愈。結(jié)論有效地應(yīng)用Onyx及彈簧圈栓塞海綿竇是成功治愈海綿竇區(qū)硬腦膜動(dòng)靜脈瘺的關(guān)鍵。合理放置彈簧圈的位置,有效地運(yùn)用Onxy彌漫性及控制性好的特點(diǎn),避免過(guò)量使用彈簧圈及Onxy,是有效治愈csDAVFs并減少并發(fā)癥發(fā)生的有益的理念。第二章經(jīng)動(dòng)脈入路使用Onyx栓塞經(jīng)靜脈入路栓塞失敗的海綿區(qū)硬腦膜動(dòng)靜脈瘺研究背景和目的經(jīng)靜脈入路栓塞海綿竇已成為治療csDAVFs的最優(yōu)先的選擇,盡管偶爾經(jīng)靜脈插管存在困難。在我們中心經(jīng)靜脈栓塞海綿竇以治療csDAVFs也已成為治療該病的優(yōu)先選擇。然而,經(jīng)常規(guī)的巖下竇或眼上靜脈插管入海綿竇偶爾會(huì)失敗。此時(shí),被建議行外科插管至眼上靜脈或經(jīng)皮經(jīng)眶穿刺插管入海綿竇,但這會(huì)帶來(lái)許多并發(fā)癥,比如眶內(nèi)血腫或者感染,及損害相鄰的顱神經(jīng)。一些神經(jīng)介入醫(yī)師償試使用皮層靜脈如顳淺靜脈及大腦中淺靜脈作為路徑插管至海綿竇,然而,暴露這些皮層靜脈需要行開(kāi)顱手術(shù)及復(fù)雜的程序。使用液體栓塞劑經(jīng)動(dòng)脈路徑栓塞海綿竇區(qū)硬腦膜動(dòng)靜脈瘺有較高的風(fēng)險(xiǎn),在于可能栓塞頸外動(dòng)脈與頸內(nèi)動(dòng)脈的腦膜支間存在的危險(xiǎn)吻合血管、神經(jīng)滋養(yǎng)血管、眼動(dòng)脈及椎動(dòng)脈。由于Onyx具有聚合性良好及低黏合性的特點(diǎn),有助于控制膠在瘺的滲透,已成為治療硬腦膜動(dòng)靜脈瘺首選的栓塞劑。已經(jīng)有人在償試用Onyx通過(guò)動(dòng)脈路徑栓塞csDAVFs, Pero等報(bào)道了3例以咽升動(dòng)脈路徑應(yīng)用Onyx栓塞csDAVFs的病例。Gandhi等報(bào)道了1例經(jīng)頜內(nèi)動(dòng)脈遠(yuǎn)端分支為路徑應(yīng)用Onyx栓塞csDAVFs的病例。Amiridze等描述了1例通過(guò)腦膜中動(dòng)脈及蝶腭動(dòng)脈應(yīng)用Onyx栓塞csDAVFs的病例。但這些個(gè)案報(bào)道均缺乏對(duì)動(dòng)脈路徑治療策略及經(jīng)驗(yàn)的總結(jié)。因此本文的主要目的是報(bào)道關(guān)于經(jīng)動(dòng)脈路徑使用Onyx栓塞經(jīng)靜脈插管失敗的csDAVFs的病人的治療經(jīng)驗(yàn)。方法與材料1.收集臨床資料回顧性分析自2010年11月至2013年6月經(jīng)靜脈路徑治療失敗,而后改行利用動(dòng)脈路徑Onyx栓塞瘺口的方式治療的csDAVFs的病人的資料,詳細(xì)回顧全部的臨床記錄、影像學(xué)資料及操作記錄。排除資料缺失、既往有顱內(nèi)疾病治療史及患有其他可能?chē)?yán)重影響患者的預(yù)期壽命疾病的病人。所有病人均按Borden-Shucart分類(lèi)及Barrow分類(lèi)方法進(jìn)行分型。2.治療方法所有病人均在在靜脈全麻下經(jīng)股動(dòng)脈插管行常規(guī)的全腦血管造影術(shù)。肝素化維持活化凝血時(shí)間在200秒至300秒間。腦血管造影包括雙側(cè)選擇性的頸內(nèi)動(dòng)脈、頸外動(dòng)脈造影,及雙側(cè)椎動(dòng)脈造影。確認(rèn)包括瘺口的位置、供血?jiǎng)用}、靜脈引流模式、側(cè)支循環(huán)及危險(xiǎn)血管吻合等信息。所有病人均優(yōu)先償試行靜脈入路栓塞海綿竇。對(duì)經(jīng)靜脈插管失敗的病人,我們采用經(jīng)動(dòng)脈路徑的方法進(jìn)行栓塞。將一根6F的指引管置入頸外動(dòng)脈內(nèi),同時(shí)對(duì)對(duì)側(cè)的股動(dòng)脈進(jìn)行穿刺插管進(jìn)行對(duì)照腦血管造影檢查。然后將一根微導(dǎo)管在一根微導(dǎo)絲的導(dǎo)引下置入盡量靠近瘺口的供血?jiǎng)用}的遠(yuǎn)端位置。再行超選擇性造影以確定最佳的導(dǎo)管頭端楔入位置,鑒別正常動(dòng)脈血管支及危險(xiǎn)吻合。在實(shí)時(shí)路圖監(jiān)控下使用“反流-停頓-再注射”技術(shù)緩慢注射Onyx。當(dāng)發(fā)現(xiàn)膠返流入非目標(biāo)區(qū)時(shí),停止注入約20秒至2分鐘,以讓Onyx沉淀下來(lái)并在導(dǎo)管頭端周?chē)纬梢粋�(gè)栓子。然后再重新注射,以盡可能地使Onyx彌漫入全部的瘺口而不栓塞危險(xiǎn)吻合及重要的血管。3.評(píng)價(jià)標(biāo)準(zhǔn)影像的評(píng)價(jià)標(biāo)準(zhǔn)為：(1)完全栓塞,沒(méi)有可以辨認(rèn)的動(dòng)靜脈分流；(2)次全栓塞,只有小的停滯不前的殘存分流而無(wú)皮層靜脈或眼靜脈的引流；(3)不完全栓塞,只有流量的減少而有明顯的分流殘存。完全及次全栓塞被認(rèn)為是成功的血管造影結(jié)果。臨床的評(píng)價(jià)標(biāo)準(zhǔn)為：(1)無(wú)癥狀；(2)改善,原有癥狀的明顯改善；(3)無(wú)改善,癥狀無(wú)改變或加重；(4)復(fù)發(fā),隨訪期新發(fā)的與病變相關(guān)的癥狀。無(wú)癥狀及癥狀明顯改善被認(rèn)為是臨床治愈。4.觀察方法對(duì)比患者栓塞前的腦血管造影的圖像與術(shù)后即刻腦血管造及隨訪腦血管造影的圖像,以確定影像學(xué)的治療效果。觀察患者出院時(shí)及隨訪期的臨床癥狀與體征,與入院時(shí)的臨床癥狀與體征對(duì)比,以確定臨床治療效果。觀察并發(fā)癥的轉(zhuǎn)歸情況。5.統(tǒng)計(jì)學(xué)方法利用SPSS 19.0統(tǒng)計(jì)軟件進(jìn)行分析。平均年齡、平均住院天數(shù)采用平均數(shù)來(lái)表示,平均隨訪期采用中位數(shù)表。結(jié)果共有8個(gè)病人經(jīng)靜脈路徑栓塞失敗,并且接受了經(jīng)動(dòng)脈路徑的Onxy栓塞。分別有4男4女,年齡范圍從26歲至57歲(平均37.88±10.64歲)。其中7個(gè)病人因微導(dǎo)管不能成功經(jīng)靜脈路徑到達(dá)海綿竇,另有1個(gè)病人因病變側(cè)的頸靜脈球以下的頸內(nèi)靜脈閉塞。所有病人在經(jīng)靜脈路徑栓塞失敗前均未接受治療。所有病人(100%,8/8)均有結(jié)膜充血,5個(gè)病人(62.5%,5/8)表現(xiàn)為突眼及球結(jié)膜水腫。經(jīng)動(dòng)脈路徑共經(jīng)歷8次栓塞及8次插管操作,其中5例經(jīng)腦膜中動(dòng)脈插管,3例經(jīng)腦膜副動(dòng)脈插管。栓塞術(shù)后即刻造影顯示7個(gè)病人(87.5%,7/8)取得了瘺的完全栓塞,1個(gè)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。所有病人術(shù)后均進(jìn)行腦血管造影隨訪復(fù)查,平均隨訪期約6個(gè)月(間隔從6個(gè)至10個(gè)月)。在隨訪終末期所有病人取得了完全栓塞。兩個(gè)病人發(fā)生與經(jīng)動(dòng)脈路徑栓塞程序相關(guān)的并發(fā)癥,1例發(fā)生與病變同側(cè)的左側(cè)的面部麻木感,另1例發(fā)生右側(cè)展神經(jīng)麻痹及球結(jié)膜水腫。經(jīng)過(guò)治療后,兩例并發(fā)癥均治愈。結(jié)論當(dāng)經(jīng)靜脈路徑栓塞海綿竇治療海綿竇區(qū)硬腦膜動(dòng)靜脈瘺困難時(shí),經(jīng)動(dòng)脈路徑栓塞瘺管提供了一個(gè)安全且有效的選擇。腦膜中動(dòng)脈及腦膜副動(dòng)脈為從動(dòng)脈路徑栓塞csDAVFs提供了較好的栓塞路徑。
[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.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類(lèi)號(hào)】：R743.3
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本文編號(hào)：2076666