本文選題：硬腦膜動靜脈瘺 + 臨床特征�。� 參考：《浙江大學(xué)》2015年博士論文

【摘要】：第一章硬腦膜動靜脈瘺預(yù)后因素分析 研究背景DAVF為硬腦膜動脈與皮層靜脈或靜脈竇的異常交通,其臨床特征各異。不同部位的DAVF在臨床癥狀、影像學(xué)表現(xiàn)、血管構(gòu)筑、治療方式與預(yù)后上各有不同。多數(shù)DAVF的自然病程為良性,然而一旦發(fā)生顱內(nèi)出血,預(yù)后多不佳。然而,由于DAVF的高度異質(zhì)性,目前尚無預(yù)測DAVF預(yù)后的相關(guān)模型。DAVF的臨床特點、影像特征治療方式與其預(yù)后的關(guān)系有待進一步探究。 目的統(tǒng)計DAVF的臨床特點、影像學(xué)特征、治療方式及預(yù)后資料,探究DAVF預(yù)后的相關(guān)因素。 方法本組病例為2010年至2015年浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院診療的79例DAVF患者,其中男性52例,女性27例,平均年齡52.2歲。收集這些病例的臨床癥狀、DAVF位置、Cognard分型、供應(yīng)血管、治療方式、治療結(jié)果、隨訪mRS評分等。根據(jù)隨訪mRS評分將患者分為預(yù)后良好與預(yù)后不佳兩組,對上述的臨床特點,行Kruskal-Wallis單因素穩(wěn)健方差分析與Logistic多因素回歸分析,探究DAVF預(yù)后的相關(guān)因素。 結(jié)果本組中自發(fā)性DAVF有70例(88.6%)。臨床癥狀中頭痛共41人次(51.9%),海綿竇癥狀32人次(40.5%),顱內(nèi)出血與NHND各13人次(16.5%)。海綿竇DAVF共31例(41.3%),橫竇乙狀竇DAVF共18例(24%),直竇DAVF共12例(16%),前顱底DAVF共9例(12%),上矢狀竇(6.7%)。Cognard分型低級別DAVF共20例(25.3%),包括Cognard Ⅰ型4例,Cognard Ⅱa型16例;高級別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%)。本組中采用TAE的有53例(67.1%),手術(shù)治療13例(16.5%),TVE治療12例(15.2%),放射治療1例(1.3%)。總治愈率為55.7%,其中手術(shù)治療的13例DAVF均達完全栓塞;TAE中22例達完全栓塞,完全栓塞率為41.5%；TVE中9例達完全栓塞,完全栓塞率率為75%。本組平均隨訪31.1月,隨訪時mRS平均分2.1士1.3,分其中預(yù)后良好(mRS≤2)43人,預(yù)后不佳(mRS2)19人。 單因素Kruskal-Wallis檢驗提示初始癥狀在DAVF預(yù)后上有顯著的差異。顱內(nèi)出血為首發(fā)癥狀的患者,其mRS評分顯著高于以頭痛或搏動性雜音為首發(fā)癥狀的患者。其他癥狀間的mRS評分無顯著差異。隨訪時癥狀無改善的病人,其mRS評分也要顯著高于隨訪時癥狀消失的病人。Logistic多因素檢驗提示隨訪時癥狀無改善是預(yù)后不良的相關(guān)因素,未發(fā)現(xiàn)其他與預(yù)后顯著相關(guān)的因素。 結(jié)論 (1)本組79例病人,平均年齡52.2±11.1歲,男性偏多,自發(fā)性DAVF常見。 (2)本組中頭痛為最常見的臨床癥狀,其次為海綿竇相關(guān)癥狀。海綿竇與橫竇乙狀竇為DAVF最高發(fā)的區(qū)域。女性DAVF多發(fā)于海綿竇,性別在DAVF發(fā)病位置上差異顯著。 (3) DAVF的位置與臨床癥狀、Cognard分型、治療方式相關(guān)。前顱底DAVF多選擇手術(shù)治療,TVE用于海綿竇與橫竇乙狀竇DAVF,TAE對于各個位置的DAVF均有使用。 (4)單因素分析中,顱內(nèi)出血是DAVF預(yù)后不良的相關(guān)因素。Logistic多因素分析下,除隨訪癥狀與DAVF預(yù)后相關(guān)外,未發(fā)現(xiàn)其他預(yù)后相關(guān)因素。對出血高風(fēng)險的患者,在顱內(nèi)出血事件發(fā)生前及時治療仍能獲得良好預(yù)后。 第二章硬腦膜動靜脈瘺的血管內(nèi)治療 研究背景DAVF的治療方法很多,包括保守觀察、手術(shù)治療、放射治療與血管內(nèi)治療。血管內(nèi)治療因其直接到達患處被認(rèn)為是DAVF最理想的治療方式。TVE一直被認(rèn)為是最安全可靠的血管內(nèi)治療途徑,TAE因不良事件嚴(yán)重與操作困難,一直難以推廣。但隨著介入技術(shù)的不斷發(fā)展,新型栓塞材料Onyx膠的發(fā)明提高了TAE的完全栓塞率與安全性。TAE對于治療DAVF的適用性、安全性與治療效果仍存爭議。 目的統(tǒng)計TAE與TVE治療DAVF的適用范圍、完全栓塞率、不良反應(yīng)與預(yù)后,評估TAE與TVE在治療DAVF上的作用。 方法本組回顧性病例對照研究。資料為2010年至2015年浙江大學(xué)醫(yī)學(xué)院附屬第二醫(yī)院行血管內(nèi)治療并完成隨訪的46例DAVF患者,分為TAE治療組與TVE治療組,以DAVF的解剖部位、Cognard分級、完全栓塞率、并發(fā)癥及隨訪mRS評分為因變量。統(tǒng)計上述變量在不同血管內(nèi)治療途徑上的差異,以評估TAE與TVE在治療DAVF上的作用。 結(jié)果本組血管內(nèi)治療患者46例,采用TAE36例,TVE10例,總體完全栓塞率52.2%,TAE組完全栓塞率44.4%,TVE組完全栓塞率為80%,兩組間差異顯著(p=0.038)。TAE組中18例位于海綿竇,9例位于橫竇與乙狀竇,6例位于直竇,2例位于上矢狀竇,1例位于前顱底,相應(yīng)完全栓塞率為38.9%,44.4%,50%,50%,100%。TVE組中5例位于海綿竇,3例位于橫竇與乙狀竇,2例位于直竇,前顱底與上矢狀竇無采用TVE治療。 TAE組中26例采用Onyx膠,8例采用n-BCA膠,2例采用彈簧圈填塞。TVE治療組中8例采用彈簧圈,1例采用Onyx膠,1例同時采用了彈簧圈與Onyx膠。TAE組中n-BCA膠完全栓塞率為50%,Onyx膠完全栓塞率42.3%,次全栓塞率23.1%,彈簧圈的完全栓塞率為50%。TVE組中彈簧圈的完全栓塞率為77.8%,次全栓塞為22.3%。TAE組患者隨訪時平均mRS為2.03±1.21,TVE組隨訪時平均mRS為0.80±1.06。兩組間患者隨訪時的mRS評分無顯著差異。TAE組術(shù)后出現(xiàn)1例患者右眼視力進一步減退,1例患者動眼神經(jīng)麻痹,TVE組術(shù)后1例自覺頭痛加重,無其他手術(shù)并發(fā)癥。 結(jié)論 (1)本組中TVE的完全栓塞率顯著高于TAE。 (2)TAE用于位于海綿竇、前顱底、橫竇乙狀竇、直竇、矢狀竇的DAVF, TVE不用于前顱底與上矢狀竇的DAVF。TVE不用于Cognard Ⅲ型以上的DAVF。 (3)TAE與TVE兩組間隨訪mRS評分無顯著差異。TAE與TVE均較少發(fā)生術(shù)后并發(fā)癥,TAE與TVE在治療DAVF中都是安全有效的。 (4)TAE較TVE有更高的性價比。隨著Onyx的應(yīng)用與TAE技術(shù)的成熟,TAE在我國等發(fā)展中國家不失為可推廣的DAVF治療方法。
[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.

【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R651.1

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相關(guān)期刊論文 前1條

1 凌鋒,伍健偉,張鴻祺,支興龍,張鵬,宋慶斌;硬腦膜動靜脈瘺的分型及臨床意義[J];中華醫(yī)學(xué)雜志;2001年23期

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