發(fā)布時間：2018-05-03 00:13

  本文選題：頸動脈海綿竇瘺 + 臨床癥狀��； 參考：《南方醫(yī)科大學(xué)》2014年碩士論文

【摘要】：研究背景： 頸動脈海綿竇瘺(carotid cavernous fistula)最早由Baron在1835年報道,是指由頸內(nèi)動脈海綿竇段或其分支破裂,導(dǎo)致頸內(nèi)動脈與海綿竇之間形成異常動靜脈交通的一組臨床綜合征,是一種少見的腦血管疾病。按發(fā)病原因,可分為外傷性和自發(fā)性,其中外傷性約占75%～85%,約占顱腦外傷的0.2-0.3%。外傷性頸動脈海綿竇瘺多發(fā)生于顱腦外傷時,顱底骨折導(dǎo)致骨折碎片直接刺破海綿竇段頸內(nèi)動脈或其分支；自發(fā)性頸動脈海綿竇瘺則主要是指在沒有外傷的情況下,由于遺傳因素、動脈粥樣硬化或海綿竇段動脈瘤破裂所致。 Santos等人報道頸動脈海綿竇瘺的臨床表現(xiàn)與引流靜脈密切相關(guān)。頸動脈海綿竇瘺的臨床表現(xiàn)包括搏動性突眼、球結(jié)膜充血水腫、顱內(nèi)血管雜音、眼球運動障礙、復(fù)視、上瞼下垂、視力減退或喪失、頭痛。部分患者還可能出現(xiàn)偏癱、失語、抽搐、顱內(nèi)出血、蛛網(wǎng)膜下腔出血、鼻出血等癥狀。發(fā)生頸動脈海綿竇瘺時,海綿竇部的靜脈引流是多方向的,主要包括：向前引流至眼靜脈,向后引流至巖上、下竇,向上引流至側(cè)裂靜脈或皮層靜脈,向下引流至翼叢以及向內(nèi)經(jīng)海綿間竇引流至對側(cè)海綿竇。Zeng等人對28例頸動脈海綿竇瘺患者的影像學(xué)資料進行分析,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?qū)?cè)引流占4.1%。對頸動脈海綿竇瘺臨床癥狀與引流靜脈之間相互關(guān)系的充分認識,有助于提高該疾病的臨床診斷率,同時對治療方式的選擇也可以提供重要幫助。目前,國內(nèi)、外學(xué)者對頸動脈海綿竇瘺臨床癥狀與引流靜脈的研究多集中于病例報道及經(jīng)驗性總結(jié),尚缺乏統(tǒng)計學(xué)研究。 另外,海綿竇在解剖關(guān)系上與部分顱神經(jīng)關(guān)系密切。海綿竇是全身唯一處靜脈包繞動脈的特殊結(jié)構(gòu),在海綿竇內(nèi)由于各種原因只要動脈或其分支破裂,即可形成動靜脈之間的直接溝通。海綿竇位于顱中窩蝶鞍兩旁,硬腦膜層與骨膜層之間,由多個分隔的靜脈腔組成。海綿竇前至眶上裂,與視神經(jīng)管和頸內(nèi)動脈床突上段相鄰；后達巖骨尖部,與頸內(nèi)靜脈和半月節(jié)相鄰；內(nèi)側(cè)與蝶竇和垂體相鄰；外側(cè)為大腦顳葉、蝶骨、圓孔、卵圓孔相鄰。海綿竇內(nèi)有頸內(nèi)動脈和腦神經(jīng)通過,在前床突和后床突之間的海綿竇外側(cè)壁的內(nèi)層中,由上而下排列著動眼神經(jīng)、滑車神經(jīng)、眼神經(jīng)和上頜神經(jīng)。海綿竇腔內(nèi)有頸內(nèi)動脈和外展神經(jīng)通過。 外展神經(jīng)起自展神經(jīng)核,自延髓腦橋溝中部發(fā)出,穿過巖斜坡硬膜進入巖下竇開口下方的基底竇外下壁,在靜脈竇內(nèi)斜行向上走行5-8mm,穿過Gruber韌帶形成的Dorello管,向前進入海綿竇后部。在竇內(nèi)外展神經(jīng)仍有硬膜包裹,與神經(jīng)隔內(nèi)筋膜融合,平行于頸內(nèi)動脈水平部外壁,達眶上裂。Shownkeen、Vesna及國內(nèi)的陳書揚等認為由于外展神經(jīng)在顱內(nèi)行程長,且途徑海綿竇內(nèi)部,頸動脈海綿竇瘺時,海綿竇的擴大及竇內(nèi)壓的升高,最易導(dǎo)致外展神經(jīng)的麻痹,表現(xiàn)為外展受限,出現(xiàn)內(nèi)斜視,影響患者的生活質(zhì)量。但目前國內(nèi)有關(guān)頸動脈海綿竇瘺致外展神經(jīng)麻痹的研究較少,僅有相關(guān)的病例報道,尚缺乏對頸動脈海綿竇瘺致外展神經(jīng)麻痹的影響因素的研究。 目前,隨著神經(jīng)介入技術(shù)的發(fā)展,血管內(nèi)介入治療已成為治療頸動脈海綿竇瘺的首選方案。其中可脫性球囊以簡單、經(jīng)濟、有效的特點成為首選的栓塞材料。隨著新型栓塞材料的出現(xiàn)及改進,彈簧圈、Onyx、NBCA、PVA顆粒及覆膜支架等亦逐漸用于頸動脈海綿竇瘺的治療。對血管內(nèi)栓塞治療頸動脈海綿竇瘺的患者進行系統(tǒng)的臨床隨訪總結(jié),能夠有效的評估栓塞效果及患者的預(yù)后,包括栓塞術(shù)后的復(fù)發(fā)及臨床癥狀的恢復(fù)等。 第一部分頸動脈海綿竇瘺的臨床癥狀與引流靜脈的關(guān)系及血管內(nèi)栓塞治療臨床隨訪總結(jié) 研究目的：歸納頸動脈海綿竇瘺的臨床、影像學(xué)特點及其治療方法,分析頸動脈海綿竇瘺臨床癥狀與引流靜脈之間的關(guān)系,探討、總結(jié)頸動脈海綿竇瘺治療、栓塞技術(shù)要點、并發(fā)癥、復(fù)發(fā)原因及處理方法。 研究方法：本文回顧性分析和總結(jié)南方醫(yī)科大學(xué)珠江醫(yī)院神經(jīng)外科自2000年1月至2013年12月收治的具有完整病歷資料的頸動脈海綿竇瘺病例156例。所有手術(shù)過程及操作均在全身肝素化及靜脈麻醉下進行。采用Seldinger技術(shù),經(jīng)股動脈插管,先行全腦血管造影,全面了解瘺口的部位、數(shù)目、瘺口大小、靜脈引流及腦循環(huán)狀況等,再行血管內(nèi)栓塞治療。根據(jù)患者不同的引流靜脈,采用x2檢驗分析其與各臨床癥狀之間的關(guān)系。并對所有患者進行臨床隨訪,隨訪 方法：主要通過患者再次入院、門診隨訪、部分電話訪問、網(wǎng)絡(luò)隨訪以及信件隨訪。隨訪內(nèi)容以有無復(fù)發(fā)及臨床癥狀恢復(fù)情況為主。統(tǒng)計資料全部采用SPSS18.0統(tǒng)計軟件進行分析處理。 研究結(jié)果：156例患者中男性99例,女性57例；年齡最大67歲,最小9歲,平均年齡(34.29±13.85)歲；治療前癥狀持續(xù)時間在1周以內(nèi)58例,1周到3周之間26例,3周到3個月之間47例,大于3個月25例；自發(fā)性頸動脈海綿竇瘺13例,創(chuàng)傷性頸動脈海綿竇瘺143例,包括車禍、跌落傷、銳器傷、斗毆、重物砸傷等；臨床表現(xiàn)搏動性突眼140例,球結(jié)膜充血水腫150例,顱內(nèi)血管雜音131例,眼球活動障礙92例,視力減退82例,復(fù)視19例,眼瞼下垂26例,頭痛39例,鼻出血2例,顱內(nèi)出血1例；有伴隨癥狀75例；22例患者栓塞術(shù)后出現(xiàn)并發(fā)癥,其中頭痛10例,顱神經(jīng)一過性麻痹7例,腦血管痙攣2例,穿刺部位血腫2例,鼻出血1例。156例患者中,復(fù)雜性、難治性頸動脈海綿竇瘺18例。 頸動脈海綿竇瘺的靜脈引流是多方向的：向前引流至眼靜脈148例,向后引流至巖上、下竇125例,向上主要引流至側(cè)裂靜脈及皮層靜脈19例,向下引流至翼叢74例。向前引流可能與搏動性突眼(x2=54.661,P=0.000)、顱內(nèi)血管雜音(x2=7.233,P=0.007)球結(jié)膜充血水腫(x2=25.824,P=0.000)、視力減退(x2=5.428,P=0.020)有關(guān)；向后引流可能與顱內(nèi)血管雜音(x2=4.675,P=0.031)、眼球運動障礙(x2=14.336,P=0.000)有關(guān)；向上引流可能與頭痛(x2=12.630,P=0.000)有關(guān)。 156例患者中148例采用血管內(nèi)栓塞治療,其中可脫性球囊栓塞133例,彈簧圈栓塞5例,兩者聯(lián)合栓塞4例,彈簧圈聯(lián)合Onyx栓塞4例,球囊聯(lián)合PVA顆粒栓塞2例。栓塞過程中有15例行頸內(nèi)動脈閉塞,頸內(nèi)動脈通暢率為89.9%。栓塞治療術(shù)后有22例出現(xiàn)并發(fā)癥,發(fā)生率14.9%。對148例患者進行隨訪,獲得隨訪116例,隨訪率78.4%。隨訪時間為3個月-2年,平均隨訪18個月。12例患者予第一次栓塞后出現(xiàn)復(fù)發(fā),復(fù)發(fā)率8.1%。其中男性7例,女性5例。4例單球囊栓塞后復(fù)發(fā),7例多球囊栓塞后復(fù)發(fā),1例彈簧圈栓塞后復(fù)發(fā)。復(fù)發(fā)時間為術(shù)后ld-65d,平均17天,其中1周內(nèi)復(fù)發(fā)8例。復(fù)發(fā)的12例患者中6例采用可脫性球囊再次栓塞后治愈,3例采用彈簧圈栓塞瘺口,1例行頸內(nèi)動脈閉塞,1例予保守壓頸治療后痊愈,1例家屬拒絕治療。顱內(nèi)血管雜音手術(shù)后立即消失108例,占95.6%；搏動性突眼2周內(nèi)恢復(fù)99例,占93.4%；球結(jié)膜充血水腫113例,2周內(nèi)恢復(fù)105例,占92.3%。神經(jīng)功能受損所致眼球運動障礙半年內(nèi)恢復(fù)或有所好轉(zhuǎn)61例,占81.3%；眼瞼下垂患者中17例1年內(nèi)恢復(fù)正常,占85%。 研究結(jié)論：(1)頸動脈海綿竇瘺的臨床表現(xiàn)與引流靜脈關(guān)系密切：向前引流可能與搏動性突眼、顱內(nèi)血管雜音、球結(jié)膜充血水腫、視力減退有關(guān)；向后引流可能與顱內(nèi)血管雜音、眼球運動障礙有關(guān)；向上引流可能與頭痛、顱內(nèi)出血或蛛網(wǎng)膜下腔出血有關(guān)。 (2)可脫性球囊栓塞頸動脈海綿竇瘺由于球囊泄氣、移位、造影劑外滲等仍存在一定的復(fù)發(fā),但復(fù)發(fā)率低,且多于栓塞后1周復(fù)發(fā)。 (3)頸動脈海綿竇瘺的預(yù)后較好,多數(shù)臨床癥狀在短期內(nèi)恢復(fù),但神經(jīng)功能受損引起的眼部癥狀恢復(fù)較慢,需要6個月～12個月左右時間。 第二部分頸動脈海綿竇瘺致外展神經(jīng)麻痹的影響因素的分析 研究目的：頸動脈海綿竇瘺患者中動眼神經(jīng)、滑車神經(jīng)、外展神經(jīng)經(jīng)常受累,導(dǎo)致眼球運動障礙,嚴重影響患者的預(yù)后及生活質(zhì)量。其中外展神經(jīng)由于特殊的解剖位置,最易受累,引起患者眼球外展受限。本文擬對頸動脈海綿竇瘺致外展神經(jīng)麻痹的影響因素進行分析,以便臨床醫(yī)生能夠充分認識并重視頸動脈海綿竇瘺患者神經(jīng)功能的受損,并有效預(yù)防及判斷其預(yù)后。 研究材料和方法：回顧性分析和總結(jié)南方醫(yī)科大學(xué)珠江醫(yī)院神經(jīng)外科自2000年1月至2013年12月收治的具有完整病歷資料的頸動脈海綿竇瘺病例156例,所有的患者均行全腦血管造影術(shù),在全身肝素化及靜脈麻醉下,采用Seldinger技術(shù),經(jīng)股動脈或股靜脈插管,先行全腦血管造影,全面了解瘺口的部位、數(shù)目、瘺口部血流量、靜脈引流方向及腦循環(huán)狀況等,再采用可脫性球囊或彈簧圈行血管內(nèi)栓塞治療。將156例患者分為外展神經(jīng)麻痹組和外展神經(jīng)非麻痹組,應(yīng)用單因素分析及二分類多因素Logistic回歸分析探討性別、年齡、發(fā)病原因、治療前癥狀持續(xù)時間、有無合并顱底骨折或顱高壓、瘺口側(cè)別、瘺口血流量、瘺口數(shù)目、有無盜血及引流靜脈等因素對外展神經(jīng)麻痹發(fā)生的影響。全部數(shù)據(jù)采用SPSS18.0統(tǒng)計軟件處理。 研究結(jié)果：156例頸動脈海綿竇瘺患者中外展神經(jīng)麻痹組74例,外展神經(jīng)非麻痹組82例。單因素分析結(jié)果顯示：治療前癥狀持續(xù)時間長(x2=4.849,P=0.028)、合并顱底骨折或顱高壓(x2=4.249,P=0.028)、瘺口血流量大(x2=4.148,P=0.042)及經(jīng)巖上、下竇引流(x2=7.259,P=0.007)是導(dǎo)致外展神經(jīng)麻痹的4個影響因素。Logistic回歸分析顯示：治療前癥狀持續(xù)時間長(R=3.074,95%CI：1.492～6.333)、合并顱底骨折或顱高壓(R=2.152,95%CI：1.090-4.248)、瘺口血流量大(R=2.736,95%CI：1.261-5.423)及經(jīng)巖上、下竇引流(R=5.075,95%CI：1.933-13.326)是導(dǎo)致外展神經(jīng)麻痹的4個獨立影響因素,其中經(jīng)巖上、下竇引流是最主要的影響因素。 研究結(jié)論：頸動脈海綿竇瘺引起外展神經(jīng)麻痹的因素是多方面的,其中經(jīng)巖上、下竇引流是最主要的影響因素。
[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 鹵 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 .

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R743

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