硬腦膜動靜脈瘺的介入診斷及治療課件

1、硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺（DAVF)發(fā)生于硬腦膜及其附屬結(jié)構(gòu)如靜脈竇、大腦鐮、小腦幕上的異常動靜脈分流約占顱內(nèi)動靜脈畸形的10%-15%可見于任何年齡，成人多見硬腦膜動靜脈瘺的介入診斷及治療”通過閱讀科技書籍，我們能豐富知識，培養(yǎng)邏輯思維能力；硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺（DAVF)發(fā)生于硬腦膜及其附屬結(jié)構(gòu)如靜脈竇、大腦鐮、小腦幕上的異常動靜脈分流約占顱內(nèi)動靜脈畸形的10%-15%可見于任何年齡，成人多見硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺（DAVF)發(fā)生于硬腦

2、膜及其附屬結(jié)構(gòu)如靜脈竇、硬腦膜動靜脈瘺（DAVF)硬腦膜竇畸形伴動靜脈瘺新生兒或嬰兒，常為巨大囊袋或硬膜湖，與其它竇或大腦靜脈以緩流交通，多累及上矢狀竇，常伴栓塞、閉鎖或一側(cè)頸內(nèi)靜脈球發(fā)育低下嬰兒型DAVF高流速，高流量，多灶性，表現(xiàn)為大的竇及多發(fā)的局部動靜脈瘺和大的供血血管，常繼發(fā)引起皮層軟膜分流，直竇常缺如；靜脈出口閉塞可引起顱壓增高，腦室積水成人型DAVF硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺（DAVF)硬腦膜竇畸形伴動靜脈瘺硬腦膜動靜脈嬰兒型DAVF多支供血?jiǎng)用}靜脈竇瘤樣擴(kuò)張梗塞性腦積水直竇缺如骨皮質(zhì)改變硬腦膜動靜脈瘺的介入診斷及治療嬰兒型DAVF多支供血?jiǎng)用}硬腦膜動靜脈瘺的介入

3、診斷及治療女，10歲 進(jìn)行性腦神經(jīng)缺失（嬰兒型DAVF）CT強(qiáng)化： 上矢狀竇擴(kuò)張，腦皮質(zhì)鈣化，白質(zhì)變薄MR T1WI：上矢狀竇及竇匯巨大流空影，小腦扁桃體下移硬腦膜動靜脈瘺的介入診斷及治療女，10歲 進(jìn)行性腦神經(jīng)缺失（嬰兒型DAVF）CT強(qiáng)化： 上成人型DAVF硬腦膜動靜脈瘺的介入診斷及治療成人型DAVF硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動脈前顱窩腦膜中動脈前支篩前、后動脈腦膜返動脈蝶腭動脈中顱窩腦膜中/副動脈頸內(nèi)動脈下外側(cè)干咽升動脈腦膜支后顱窩椎動脈腦膜支腦膜垂體干枕動脈腦膜支腦膜中動脈后支咽升動脈腦膜支大腦后動脈分支小腦上動脈分支小腦下后動脈分支硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動脈前

4、顱窩后顱窩硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療發(fā)病機(jī)制DAVF與手術(shù)、頭外傷、感染、硬腦膜竇血栓形成、雌激素等因素有關(guān)，但確切發(fā)病機(jī)制不明兩種假說“生理性動靜脈交通”開放：硬腦膜動靜脈之間存“生理性動靜脈交通”（dormant channels)或“裂隙樣血管”（crack-like vessels），某些病理狀態(tài)使其開放，形成DAVF新生血管：某些血管生長因子異常釋放促使硬腦膜新生血管形成，致使DAVF形成硬腦膜動靜脈瘺的介入診斷及治療發(fā)病機(jī)制DAVF與手術(shù)、頭外傷、感染、硬腦膜竇血栓形成、雌激分型按靜脈引流方向分型：與臨床表現(xiàn)及預(yù)后密切

5、相關(guān)按DAVF部位分型：與血供來源及治療途徑密切相關(guān)靜脈引流方向與病變部位相結(jié)合分型硬腦膜動靜脈瘺的介入診斷及治療分型按靜脈引流方向分型：與臨床表現(xiàn)及預(yù)后密切相關(guān)硬腦膜動靜脈按靜脈引流方向分型Borden classification1 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)Cogna

6、rd classificationI Venous drainage into dural venous sinus with antegrade flowIIa Venous drainage into dural venous 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 dr

7、ainage directly into subarachnoid veins (CVR only)IV Type III with venous ectasias of the draining subarachnoid veinsV Venous drainage into the perimedullary plexusCVR=cortical venous reflux（可能與靜脈竇閉塞有關(guān)）硬腦膜動靜脈瘺的介入診斷及治療按靜脈引流方向分型Borden classification硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的介入診斷及治療硬腦膜動靜脈瘺的

8、介入診斷及治療按DAVF部位分型海綿竇DAVF橫竇乙狀竇DAVF小腦幕DAVF上矢狀竇DAVF前顱窩DAVF邊緣竇DAVF巖上/下竇DAVF舌下神經(jīng)管DAVF硬腦膜動靜脈瘺的介入診斷及治療按DAVF部位分型海綿竇DAVF硬腦膜動靜脈瘺的介入診斷及治臨床表現(xiàn)良性DAVF搏動性雜音眼眶充血顱神經(jīng)麻痹慢性頭痛無癥狀侵襲性DAVF顱內(nèi)出血顱內(nèi)高壓非出血局部神經(jīng)缺失血管性癡呆死亡Borden type 1Cognard typeI/aBorden type 2/3Cognard type IIb-皮層靜脈返流（CVR)或深靜脈引流是預(yù)后不良的重要因素硬腦膜動靜脈瘺的介入診斷及治療臨床表現(xiàn)良性DAVF侵襲

9、性DAVFBorden type 1搏動性突眼球結(jié)膜水腫和充血眶周雜音進(jìn)行性視力下降顱神經(jīng)麻痹雜音，耳鳴，頭痛眼部癥狀顱內(nèi)出血（少見）雜音，耳鳴顱內(nèi)出血中樞神經(jīng)缺失頭痛顱內(nèi)出血中樞神經(jīng)缺失，癡呆顱內(nèi)出血頭痛硬腦膜動靜脈瘺的介入診斷及治療搏動性突眼雜音，耳鳴，頭痛雜音，耳鳴頭痛顱內(nèi)出血硬腦膜動靜脈診斷經(jīng)顱多普勒：可探測血流動力學(xué)改變，特異性較低CT與MRI:對良性DAVF敏感性較低；對侵襲性DAVF，可顯示異常血管，顱內(nèi)出血，局部占位效應(yīng)，腦水腫，腦積水，靜脈竇血栓形成及顱骨骨質(zhì)異常等征象CTA與MRA：可清楚顯示異常增粗的供血?jiǎng)用}和擴(kuò)張的引流靜脈及靜脈竇，對瘺口位置及“危險(xiǎn)吻合”顯示欠佳硬腦膜

10、動靜脈瘺的介入診斷及治療診斷經(jīng)顱多普勒：可探測血流動力學(xué)改變，特異性較低硬腦膜動靜脈診斷DSA供血?jiǎng)用}瘺口位置引流靜脈靜脈竇擴(kuò)張與閉塞腦循環(huán)異常硬腦膜動靜脈瘺的介入診斷及治療診斷DSA硬腦膜動靜脈瘺的介入診斷及治療 Male,62 tentorial DAVF（Cognard ）The left lateral ICA angiogram shows a tentorial DAVF fed by an inferior marginal tentorial artery draining into a cortical veinL-ICA硬腦膜動靜脈瘺的介入診斷及治療 Male,62 ten

11、torial DAV Male,49 DAVF of anterior cranial fossa （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 dilatation at the site of parenchymal hemorrha

12、geL-ICA硬腦膜動靜脈瘺的介入診斷及治療 Male,49 DAVF of anterior crtentorial DAVF（Cognard ）R-ICA硬腦膜動靜脈瘺的介入診斷及治療tentorial DAVF（Cognard ）R-IC術(shù)后1年MR示上矢狀竇血栓形成，3年后自感顱內(nèi)雜音，MR示腦表多發(fā)迂曲血管流空影；左側(cè)頸外動脈造影側(cè)位，左側(cè)橫竇DAVF伴CVR，同側(cè)乙狀竇閉塞 女，37腎移植術(shù)后，左橫竇DAVF（Cognard a+b）硬腦膜動靜脈瘺的介入診斷及治療術(shù)后1年MR示上矢狀竇血栓形成，3年后自感顱內(nèi)雜音，MR示腦巖上竇DAVF（Cognard )向脊髓靜脈引流右腦膜中動脈

13、后支，右枕動脈腦膜支及右側(cè)腦膜垂體干供血硬腦膜動靜脈瘺的介入診斷及治療巖上竇DAVF（Cognard )向脊髓靜脈引流RECA造影：右側(cè)海綿竇DAVF，引流至眼上靜脈及皮層靜脈男，58右眼球結(jié)膜充血水腫硬腦膜動靜脈瘺的介入診斷及治療RECA造影：右側(cè)海綿竇DAVF，引流至眼上靜脈及皮層靜脈治療保守治療立體定向放射治療血管內(nèi)介入治療外科手術(shù)硬腦膜動靜脈瘺的介入診斷及治療治療保守治療硬腦膜動靜脈瘺的介入診斷及治療介入治療策略經(jīng)動脈微粒栓塞（TAE-微粒）：難以達(dá)到完全栓塞，通常用于緩解癥狀或輔助治療經(jīng)靜脈彈簧圈栓塞(TVE)：治愈性手段，必須致密栓塞，否則可使癥狀惡化；可并發(fā)靜脈壁損傷，顱內(nèi)出血經(jīng)

14、動脈NBCA/Onyx栓塞(TAE)：用于復(fù)雜DAVF不能通過靜脈途徑栓塞時(shí)，完全栓塞率較高；可造成異位栓塞，對操作技術(shù)要求高支架植入：其支撐力可恢復(fù)靜脈竇正常引流并可封閉位于靜脈竇壁上的瘺口；遠(yuǎn)期效果待進(jìn)一步觀察硬腦膜動靜脈瘺的介入診斷及治療介入治療策略經(jīng)動脈微粒栓塞（TAE-微粒）：難以達(dá)到完全栓塞海綿竇DAVF保守放療TAE微粒TVETAENBCA硬腦膜動靜脈瘺的介入診斷及治療海綿竇DAVF保守硬腦膜動靜脈瘺的介入診斷及治療海綿竇DAVF經(jīng)靜脈途徑是首選的治愈性的方法經(jīng)巖下竇入路（閉塞時(shí)亦可通過）經(jīng)眼上靜脈入路其它入路：巖上竇、對側(cè)海綿竇、基底靜脈叢硬腦膜動靜脈瘺的介入診斷及治療海綿竇D

15、AVF經(jīng)靜脈途徑是首選的治愈性的方法硬腦膜動靜脈瘺的 Spontaneous regression of a cavernous sinus DAVFT2WI image 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 resol

16、ution of the flow voidsL-ECA硬腦膜動靜脈瘺的介入診斷及治療 Spontaneous regression of aLeft ECA angiogram shows a cavernous 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 d

17、ural AVFnow drains into the superior ophthalmic vein and the superficial middle cerebral vein .Althoughthe patients symptoms were unchanged, occlusion ofthe DAVF was indicatedTVE of DAVF via an occluded inferior petrosal sinusL硬腦膜動靜脈瘺的介入診斷及治療Left ECA angiogram shows a cavSuperselective venogram show

18、s that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein Left CCA angiogram obtained after TVE shows complete occlusion of the DAVFTVE of DAVF via an occluded inferior petrosal sinus硬腦膜動靜脈瘺的介入診斷及治療Superselective venogram shows 橫竇乙狀竇DAVF放療+TAE-微粒硬腦膜動靜脈瘺

19、的介入診斷及治療橫竇乙狀竇DAVF放療+TAE-微粒硬腦膜動靜脈瘺的介入診橫竇乙狀竇DAVFTVE（可先栓塞供血?jiǎng)用}）放療+TAE-微粒支架植入+TAE-微粒+放療TVE避免栓塞正常皮層靜脈引流系統(tǒng)硬腦膜動靜脈瘺的介入診斷及治療橫竇乙狀竇DAVFTVE（可先栓塞供血?jiǎng)用}）TVE避免栓塞橫竇乙狀竇DAVFTVE（可先栓塞供血?jiǎng)用}）支架植入受累靜脈竇及返流皮層靜脈近端必須致密栓塞，以防再通致腦出血硬腦膜動靜脈瘺的介入診斷及治療橫竇乙狀竇DAVFTVE（可先栓塞供血?jiǎng)用}）受累靜脈竇及返橫竇乙狀竇DAVFTVE（手術(shù)入路、經(jīng)閉塞靜脈竇入路、經(jīng)皮層靜脈入路）TAE-NBCA手術(shù)切除（可先栓塞供血?jiǎng)用}）操

20、作難度大，要求技術(shù)高硬腦膜動靜脈瘺的介入診斷及治療橫竇乙狀竇DAVFTVE（手術(shù)入路、經(jīng)閉塞靜脈竇入路、經(jīng)皮The lateral left ECA angiogram shows a DAVF of the transverse sinus with CVR and occlusion of the ipsilateral sigmoid sinus. A transvenous approach via the contralateral transverse sinus allowed selective catheterization of a parallel channel. Ve

21、nography in this parallel channel shows the veins that were draining the fistulaConversion of an aggressive DAVF to a benign(G3) 硬腦膜動靜脈瘺的介入診斷及治療The lateral left ECA angiogramThis parallel channel was embolized with a combination of platinum coils and Hydrocoil A control left ECA arteriogram shows th

22、at the CVR was eliminated, although the fistula persistsConversion of an aggressive DAVF to a benign(G3) 硬腦膜動靜脈瘺的介入診斷及治療This parallel channel was emboThe venous phase of the lateral CCA angiograms before and after treatment, we see that these cortical veins can participate in the venous drainage of

23、the brain after disconnection難以完全治愈時(shí)，可將侵襲性DAVF轉(zhuǎn)化為良性DAVFConversion of an aggressive DAVF to a benign(G3) 硬腦膜動靜脈瘺的介入診斷及治療The venous phase of the latera Early arterial phase left CCA angiogram shows a transverse-sigmoid sinus DAVF. Late arterial phase left CCA angiogram shows that the left sigmoid sinu

24、s is occluded and the dural AVF drains mainly into cortical veins and the posterior condylar vein. Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein into the affected sinusRecanalization of a transverse-sigmoid sinus DAVF after TVE硬腦膜動靜脈瘺的介入診斷及治療 Ea

25、rly arterial phase left CCALeft CCA angiogram obtained after TVE shows disappearance of the AVF. CT scan obtained 2 months 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 Re

26、canalization of a transverse-sigmoid sinus DAVF after TVE可能與栓塞不致密有關(guān)硬腦膜動靜脈瘺的介入診斷及治療Left CCA angiogram obtained af小腦幕DAVF只經(jīng)軟腦膜靜脈引流Cognard III /IV，; Borden 3侵襲性DAVF，顱內(nèi)出血風(fēng)險(xiǎn)大治療難度大老年及一般狀況差的患者可考慮放射治療硬腦膜動靜脈瘺的介入診斷及治療小腦幕DAVF只經(jīng)軟腦膜靜脈引流硬腦膜動靜脈瘺的介入診斷及治Treatment Options for Tentorial Dural AVFsTreatment Option*Resu

27、lts Radiation therapy Complete occlusion (50%60%) Intervention TAE with n-butyl-2-cyanoacrylate Complete occlusion (50%100%)TVE Complete occlusion (90%100% in few case reports) Surgery (disconnection of Complete occlusion (100%)leptomeningeal venous drainage) *Surgery and TAE with n-butyl-2-cyanoacr

28、ylate are equal in terms of potential risk and technical difficulty; they are more potentially risky and technically difficult than radiation therapy and less so than TVE.硬腦膜動靜脈瘺的介入診斷及治療Treatment Options for Tentoriatentorial dural AVF （Cognard IV）Left ECA angiogram shows a tentorial dural AVFwith l

29、eptomeningeal-cortical venous drainage and venous ectasia Lateral radiograph shows the plannedradiation field Left CCA angiogram obtained 8 months after radiation therapyshows complete obliteration of the tentorial dural AVF硬腦膜動靜脈瘺的介入診斷及治療tentorial dural AVF （Cog Male,62, presented with a brain stem

30、 hemorrhageThe left ICA angiogram shows a DAVF fed by an inferior marginal tentorial artery draining into a cortical vein. Using a transvenous approach catheterization of the venous pouch was feasible. Coils were deposited within the cortical vein and the venous pouch 硬腦膜動靜脈瘺的介入診斷及治療 Male,62, presen

31、ted with a 上矢狀竇DAVF發(fā)生與上矢狀竇血栓形成密切相關(guān)經(jīng)靜脈途徑栓塞困難，常需經(jīng)手術(shù)入路靜脈竇栓塞或手術(shù)治療部分病例（瘺口較大）可經(jīng)動脈行靜脈竇栓塞（靜脈竇無正常靜脈引流）硬腦膜動靜脈瘺的介入診斷及治療上矢狀竇DAVF發(fā)生與上矢狀竇血栓形成密切相關(guān)硬腦膜動靜脈瘺Treatment Options for Superior Sagittal Sinus Dural AVFsTreatment Option* Results Radiation therapy Unknown Intervention TAE with particles Complete occlusion (ra

32、re) 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 reports) Surgery (sinus isolation or resection) Complete occlusion (90%100%) combined with intervention *Treatm

33、ent options in decreasing order of potential risk and technical difficulty are TAE with n-butyl-2-cyanoacrylate,surgery, TVE, and radiation therapy.硬腦膜動靜脈瘺的介入診斷及治療Treatment Options for SuperiorSuperior sagittal sinus dural AVF Right ECA angiogram shows a dural AVF with cortical reflux and occlusion

34、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 middle meningeal artery Right ECA angiogram obtained after embolization shows obliteration of the AVF硬腦膜動靜脈瘺

35、的介入診斷及治療Superior sagittal sinus d前顱窩DAVF多由雙側(cè)眼動脈的篩動脈供血經(jīng)軟腦膜靜脈引流Cognard III /IV; Borden 3侵襲性DAVF，顱內(nèi)出血風(fēng)險(xiǎn)大外科手術(shù)相對安全，療效好硬腦膜動靜脈瘺的介入診斷及治療前顱窩DAVF多由雙側(cè)眼動脈的篩動脈供血硬腦膜動靜脈瘺的介入Treatment Options for Anterior Fossa Dural AVFsTreatment Option* ResultsRadiation therapy UnknownIntervention TAE with n-butyl-2-cyanoacrylate

36、 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-cyanoacrylate are equal in terms of potential risk and technical difficulty; they