硬脑膜动静脉瘘的介入诊断及治疗讲稿.ppt

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1、关于硬脑膜动静脉瘘的介入诊断及治疗第一页，讲稿共五十五页哦硬脑膜动静脉瘘（DAVF)发生于硬脑膜及其附属结构如静脉窦、大脑镰、小脑幕上的异常动静脉分流约占颅内动静脉畸形的10%-15%可见于任何年龄，成人多见第二页，讲稿共五十五页哦硬脑膜动静脉瘘（DAVF)硬脑膜窦畸形伴动静脉瘘新生儿或婴儿，常为巨大囊袋或硬膜湖，与其它窦或大脑静脉以缓流交通，多累及上矢状窦，常伴栓塞、闭锁或一侧颈内静脉球发育低下婴儿型DAVF高流速，高流量，多灶性，表现为大的窦及多发的局部动静脉瘘和大的供血血管，常继发引起皮层软膜分流，直窦常缺如；静脉出口闭塞可引起颅压增高，脑室积水成人型DAVF第三页，讲稿共五十五页哦婴儿

2、型DAVF多支供血动脉静脉窦瘤样扩张梗塞性脑积水直窦缺如骨皮质改变第四页，讲稿共五十五页哦女，女，1010岁岁 进行性脑神经缺失（婴儿型进行性脑神经缺失（婴儿型DAVFDAVF）CT强化：上矢状窦扩张，脑皮质钙化，白质变薄MR T1WI：上矢状窦及窦汇巨大流空影，小脑扁桃体下移第五页，讲稿共五十五页哦成人型DAVF第六页，讲稿共五十五页哦硬脑膜动脉前颅窝脑膜中动脉前支筛前、后动脉脑膜返动脉蝶腭动脉中颅窝脑膜中/副动脉颈内动脉下外侧干咽升动脉脑膜支后颅窝椎动脉脑膜支脑膜垂体干枕动脉脑膜支脑膜中动脉后支咽升动脉脑膜支大脑后动脉分支小脑上动脉分支小脑下后动脉分支第七页，讲稿共五十五页哦第八页，讲稿共

3、五十五页哦发病机制DAVF与手术、头外伤、感染、硬脑膜窦血栓形成、雌激素等因素有关，但确切发病机制不明两种假说“生理性动静脉交通”开放：硬脑膜动静脉之间存“生理性动静脉交通”（dormant channels)或“裂隙样血管”（crack-like vessels），某些病理状态使其开放，形成DAVF新生血管：某些血管生长因子异常释放促使硬脑膜新生血管形成，致使DAVF形成第九页，讲稿共五十五页哦分型按静脉引流方向分型：与临床表现及预后密切相关按DAVF部位分型：与血供来源及治疗途径密切相关静脉引流方向与病变部位相结合分型第十页，讲稿共五十五页哦按静脉引流方向分型Borden classifi

4、cation1 Venous drainage directly into dural venous sinus or meningeal vein2 Venous drainage into dural venous sinus with CVR3 Venous drainage directly into subarachnoid veins(CVR only)Cognard classificationI Venous drainage into dural venous sinus with antegrade flowIIa Venous drainage into dural ve

5、nous sinus with retrograde flowIIb Venous drainage into dural venous sinus with antegrade flow and CVRIIa+b Venous drainage into dural venous sinus with retrograde flow and CVRIII Venous drainage directly into subarachnoid veins(CVR only)IV Type III with venous ectasias of the draining subarachnoid

6、veinsV Venous drainage into the perimedullary plexusCVR=cortical venous reflux（可能与静脉窦闭塞有关）第十一页，讲稿共五十五页哦第十二页，讲稿共五十五页哦第十三页，讲稿共五十五页哦按DAVF部位分型海绵窦DAVF横窦乙状窦DAVF小脑幕DAVF上矢状窦DAVF前颅窝DAVF边缘窦DAVF岩上/下窦DAVF舌下神经管DAVF第十四页，讲稿共五十五页哦临床表现v良性DAVF搏动性杂音眼眶充血颅神经麻痹慢性头痛无症状v侵袭性DAVF颅内出血颅内高压非出血局部神经缺失血管性痴呆死亡Borden type 1Cognard t

7、ypeI/aBorden type 2/3Cognard type IIb-皮层静脉返流（CVR)或深静脉引流是预后不良的重要因素第十五页，讲稿共五十五页哦v搏动性突眼v球结膜水肿和充血v眶周杂音v进行性视力下降v颅神经麻痹v杂音，耳鸣，头痛v眼部症状v颅内出血（少见）v杂音，耳鸣v颅内出血v中枢神经缺失v头痛v颅内出血v中枢神经缺失，痴呆v颅内出血v头痛第十六页，讲稿共五十五页哦诊断经颅多普勒：可探测血流动力学改变，特异性较低CT与MRI:对良性DAVF敏感性较低；对侵袭性DAVF，可显示异常血管，颅内出血，局部占位效应，脑水肿，脑积水，静脉窦血栓形成及颅骨骨质异常等征象CTA与MRA：可清

8、楚显示异常增粗的供血动脉和扩张的引流静脉及静脉窦，对瘘口位置及“危险吻合”显示欠佳第十七页，讲稿共五十五页哦诊断DSA供血动脉瘘口位置引流静脉静脉窦扩张与闭塞脑循环异常第十八页，讲稿共五十五页哦 Male,62 tentorial Male,62 tentorial DAVFDAVF（Cognard Cognard）The left lateral ICA angiogram shows a tentorial DAVF fed by an inferior marginal tentorial artery draining into a cortical veinL-ICA第十九页，讲稿共

9、五十五页哦 Male,49 DAVF of anterior cranial fossa Male,49 DAVF of anterior cranial fossa（Cognard Cognard）The left lateral internal carotid arteriogram demonstrates a DAVF supplied by the anterior ethmoidal branches of the ophthalmic artery and the draining intracranial vein with a focal aneurysmal dilata

10、tion at the site of parenchymal hemorrhageL-ICA第二十页，讲稿共五十五页哦tentorialtentorial DAVFDAVF（Cognard Cognard）R-ICA第二十一页，讲稿共五十五页哦术后1年MR示上矢状窦血栓形成，3年后自感颅内杂音，MR示脑表多发迂曲血管流空影；左侧颈外动脉造影侧位，左侧横窦DAVF伴CVR，同侧乙状窦闭塞 女，女，3737肾移植术后，左横窦肾移植术后，左横窦DAVFDAVF（Cognard a+bCognard a+b）第二十二页，讲稿共五十五页哦岩上窦岩上窦DAVFDAVF（Cognard)Cognard)向

11、脊髓静脉引流向脊髓静脉引流右脑膜中动脉后支，右枕动脉脑膜支及右侧脑膜垂体干供血第二十三页，讲稿共五十五页哦RECA造影：右侧海绵窦DAVF，引流至眼上静脉及皮层静脉男，男，5858右眼球结膜充血水肿右眼球结膜充血水肿第二十四页，讲稿共五十五页哦治疗保守治疗立体定向放射治疗血管内介入治疗外科手术第二十五页，讲稿共五十五页哦介入治疗策略经动脉微粒栓塞（TAE-微粒）：难以达到完全栓塞，通常用于缓解症状或辅助治疗经静脉弹簧圈栓塞(TVE)：治愈性手段，必须致密栓塞，否则可使症状恶化；可并发静脉壁损伤，颅内出血经动脉NBCA/Onyx栓塞(TAE)：用于复杂DAVF不能通过静脉途径栓塞时，完全栓塞率较

12、高；可造成异位栓塞，对操作技术要求高支架植入：其支撑力可恢复静脉窦正常引流并可封闭位于静脉窦壁上的瘘口；远期效果待进一步观察第二十六页，讲稿共五十五页哦海绵窦DAVF保守放疗TAE微粒TVETAENBCA第二十七页，讲稿共五十五页哦海绵窦DAVF经静脉途径是首选的治愈性的方法经岩下窦入路（闭塞时亦可通过）经眼上静脉入路其它入路：岩上窦、对侧海绵窦、基底静脉丛第二十八页，讲稿共五十五页哦 Spontaneous regression of a cavernous sinus Spontaneous regression of a cavernous sinus DAVFDAVFT2WI imag

13、e shows multiple flow voids in the posterior cavernous sinus Left ECA angiogram shows a cavernous sinus dural AVF with posterior drainage into the inferior and superior petrosal sinuses Follow-up MR image shows resolution of the flow voidsL-ECAL-ECA第二十九页，讲稿共五十五页哦Left ECA angiogram shows a cavernous

14、sinus DAVF draining mainly into the inferiorpetrosal sinus and pterygopharyngeal plexus Follow-up angiogram obtained 3 monthslater shows that the inferior petrosal sinus is occluded,and the dural AVFnow drains into the superior ophthalmic vein and the superficial middle cerebral vein.Althoughthe pat

15、ients symptoms were unchanged,occlusion ofthe DAVF was indicatedTVE of DAVF via an occluded inferior petrosal sinusTVE of DAVF via an occluded inferior petrosal sinusL第三十页，讲稿共五十五页哦Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior oph

16、thalmic vein Left CCA angiogram obtained after TVE shows complete occlusion of the DAVFTVE of DAVF via an occluded inferior petrosal sinusTVE of DAVF via an occluded inferior petrosal sinus第三十一页，讲稿共五十五页哦横窦乙状窦DAVF放疗+TAE-微粒第三十二页，讲稿共五十五页哦横窦乙状窦DAVFTVE（可先栓塞供血动脉）放疗+TAE-微粒支架植入+TAE-微粒+放疗TVE避免栓塞正常皮层静脉引流系统第三十

17、三页，讲稿共五十五页哦横窦乙状窦DAVFTVE（可先栓塞供血动脉）支架植入受累静脉窦及返流皮层静脉近端必须致密栓塞，以防再通致脑出血第三十四页，讲稿共五十五页哦横窦乙状窦DAVFTVE（手术入路、经闭塞静脉窦入路、经皮层静脉入路）TAE-NBCA手术切除（可先栓塞供血动脉）操作难度大，要求技术高第三十五页，讲稿共五十五页哦The lateral left ECA angiogram shows a DAVF of the transverse sinus with CVR and occlusion of the ipsilateral sigmoid sinus.A transvenous

18、approach via the contralateral transverse sinus allowed selective catheterization of a parallel channel.Venography in this parallel channel shows the veins that were draining the fistulaConversion of an aggressive DAVF to a benign(G3)Conversion of an aggressive DAVF to a benign(G3)第三十六页，讲稿共五十五页哦This

19、 parallel channel was embolized with a combination of platinum coils and Hydrocoil A control left ECA arteriogram shows that the CVR was eliminated,although the fistula persistsConversion of an aggressive DAVF to a benign(G3)Conversion of an aggressive DAVF to a benign(G3)第三十七页，讲稿共五十五页哦The venous ph

20、ase of the lateral CCA angiograms before and after treatment,we see that these cortical veins can participate in the venous drainage of the brain after disconnection难以完全治愈时，可将侵袭性DAVF转化为良性DAVFConversion of an aggressive DAVF to a benign(G3)Conversion of an aggressive DAVF to a benign(G3)第三十八页，讲稿共五十五页

21、哦 Early arterial phase left CCA angiogram shows a transverse-sigmoid sinus DAVF.Late arterial phase left CCA angiogram shows that the left sigmoid sinus is occluded and the dural AVF drains mainly into cortical veins and the posterior condylar vein.Superselective venogram shows a microcatheter that

22、has been advanced via the posterior condylar vein into the affected sinusRecanalization of a transverse-sigmoid sinus DAVF after TVERecanalization of a transverse-sigmoid sinus DAVF after TVE第三十九页，讲稿共五十五页哦Left CCA angiogram obtained after TVE shows disappearance of the AVF.CT scan obtained 2 months

23、after TVE shows a massive hemorrhage in the left temporal lobe.Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet Recanalization of a transverse-sigmoid sinus DAVF after TVERecanalization of a transverse-sigmoid sinus DAVF after TVE可能与栓塞不致密

24、有关第四十页，讲稿共五十五页哦小脑幕DAVF只经软脑膜静脉引流Cognard III/IV，;Borden 3侵袭性DAVF，颅内出血风险大治疗难度大老年及一般状况差的患者可考虑放射治疗第四十一页，讲稿共五十五页哦Treatment Options for Tentorial Dural AVFsTreatment Option*Results Radiation therapy Complete occlusion(50%60%)Intervention TAE with n-butyl-2-cyanoacrylate Complete occlusion(50%100%)TVE Compl

25、ete occlusion(90%100%in few case reports)Surgery(disconnection of Complete occlusion(100%)leptomeningeal venous drainage)*Surgery and TAE with n-butyl-2-cyanoacrylate are equal in terms of potential risk and technical difficulty;they are more potentially risky and technically difficult than radiatio

26、n therapy and less so than TVE.第四十二页，讲稿共五十五页哦tentorial dural AVFtentorial dural AVF （Cognard IVCognard IV）Left ECA angiogram shows a tentorial dural AVFwith leptomeningeal-cortical venous drainage and venous ectasia Lateral radiograph shows the plannedradiation field Left CCA angiogram obtained 8 mo

27、nths after radiation therapyshows complete obliteration of the tentorial dural AVF第四十三页，讲稿共五十五页哦 Male,62,presented with a brain stem hemorrhage Male,62,presented with a brain stem hemorrhageThe left ICA angiogram shows a DAVF fed by an inferior marginal tentorial artery draining into a cortical vein

28、.Using a transvenous approach catheterization of the venous pouch was feasible.Coils were deposited within the cortical vein and the venous pouch 第四十四页，讲稿共五十五页哦上矢状窦DAVF发生与上矢状窦血栓形成密切相关经静脉途径栓塞困难，常需经手术入路静脉窦栓塞或手术治疗部分病例（瘘口较大）可经动脉行静脉窦栓塞（静脉窦无正常静脉引流）第四十五页，讲稿共五十五页哦Treatment Options for Superior Sagittal Sinu

29、s Dural AVFsTreatment Option*Results Radiation therapy Unknown Intervention TAE with particles Complete occlusion(rare)TVE Complete occlusion(90%100%)TAE with n-butyl-2-cyanoacrylate Complete occlusion(90%100%)Transarterial sinus catheterization Complete occlusion(100%in case and coil embolizatio re

30、ports)Surgery(sinus isolation or resection)Complete occlusion(90%100%)combined with intervention *Treatment options in decreasing order of potential risk and technical difficulty are TAE with n-butyl-2-cyanoacrylate,surgery,TVE,and radiation therapy.第四十六页，讲稿共五十五页哦Superior sagittal sinus dural AVF Su

31、perior sagittal sinus dural AVF Right ECA angiogram shows a dural AVF with cortical reflux and occlusion of the superior sagittal sinus Right ECA angiogram obtained during transarterial sinus embolization shows a microcatheter that has been advanced into the superior sagittal sinus via the right mid

32、dle meningeal artery Right ECA angiogram obtained after embolization shows obliteration of the AVF第四十七页，讲稿共五十五页哦前颅窝DAVF多由双侧眼动脉的筛动脉供血经软脑膜静脉引流Cognard III/IV;Borden 3侵袭性DAVF，颅内出血风险大外科手术相对安全，疗效好第四十八页，讲稿共五十五页哦Treatment Options for Anterior Fossa Dural AVFsTreatment Option*ResultsRadiation therapy Unknown

33、Intervention TAE with n-butyl-2-cyanoacrylate Complete occlusion(90%100%in a few case reports)TVE with a retrograde cortical Complete occlusion(90%100%in venous approach a few case reports)Surgery(disconnection of Complete occlusion(100%)leptomeningeal venous drainage)*TVE and TAE with n-butyl-2-cya

34、noacrylate are equal in terms of potential risk and technical difficulty;they are more potentially risky and technically difficult than surgery,which in turn is more so than radiation therapy.第四十九页，讲稿共五十五页哦 Anterior fossa dural AVFAnterior fossa dural AVFUnenhanced CT scan shows intracranial hemorrh

35、age at the frontal base Left ICA angiogram shows a dural AVF that is fed by the ethmoidal artery and drains into theleptomeningeal vein,which demonstrates varices Left ICA angiogram obtained after clipping of the draining vein shows disappearance of the AVFL-ICAL-ICA第五十页，讲稿共五十五页哦男，男，39 39 前颅窝前颅窝DAVF

36、DAVF右颈内动脉造影：前颅窝DAVF，由增粗的筛前动脉供血，向前引流至上矢状窦，向深部引流至岩上窦左颈内动脉造影：左侧筛前动脉参与供血R-ICAR-ICAL-ICAL-ICA第五十一页，讲稿共五十五页哦男，男，39 39 前颅窝前颅窝DAVFDAVF经上矢状窦置入微导管，颈内动脉证实微导管头位于引流静脉瘤样扩张处，应用两枚电解弹簧圈栓塞R-ICAR-ICA第五十二页，讲稿共五十五页哦男，男，39 39 前颅窝前颅窝DAVFDAVFR-ICAR-ICAL-ICAL-ICA第五十三页，讲稿共五十五页哦参考文献Hiro Kiyosue,Yuzo Hori,Mika Okahara,et al.Tr

37、eatment of Intracranial Dural Arteriovenous Fistulas:Current Strategies Based on Location and Hemodynamics,and Alternative Techniques of Transcatheter Embolization1.RadioGraphics 2004;24:16371653.Robert W.Hurst,Robert H.Rosenwasser.INTERVENTIONAL NEURORADIOLOGY.335-351第五十四页，讲稿共五十五页哦感感谢谢大大家家观观看看第五十五页，讲稿共五十五页哦