硬腦膜動(dòng)靜脈瘺的介入診斷及治療.ppt

1、,硬腦膜動(dòng)靜脈瘺的介入診斷及治療,硬腦膜動(dòng)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(dòng)靜脈分流 約占顱內(nèi)動(dòng)靜脈畸形的10%-15% 可見于任何年齡，成人多見,硬腦膜動(dòng)靜脈瘺（DAVF),硬腦膜竇畸形伴動(dòng)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(dòng)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,嬰兒型DAVF,多支供血?jiǎng)用} 靜脈竇瘤樣擴(kuò)張 梗塞性腦積

2、水 直竇缺如 骨皮質(zhì)改變,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,成人型DAVF,硬腦膜動(dòng)脈,前顱窩 腦膜中動(dòng)脈前支 篩前、后動(dòng)脈 腦膜返動(dòng)脈 蝶腭動(dòng)脈 中顱窩 腦膜中/副動(dòng)脈 頸內(nèi)動(dòng)脈下外側(cè)干 咽升動(dòng)脈腦膜支,后顱窩 椎動(dòng)脈腦膜支 腦膜垂體干 枕動(dòng)脈腦膜支 腦膜中動(dòng)脈后支 咽升動(dòng)脈腦膜支 大腦后動(dòng)脈分支 小腦上動(dòng)脈分支 小腦下后動(dòng)脈分支,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(dòng)靜脈交通”開放：硬腦膜動(dòng)靜脈之

3、間存“生理性動(dòng)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(zhǎng)因子異常釋放促使硬腦膜新生血管形成，致使DAVF形成,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) 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,按靜脈引流方向分型,CVR=cortical venous reflux（可能與靜脈竇閉塞有關(guān)）,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DA

4、VF 舌下神經(jīng)管DAVF,臨床表現(xiàn),良性DAVF 搏動(dòng)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 1 Cognard typeI/a,Borden type 2/3 Cognard 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,搏動(dòng)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,診斷,經(jīng)顱多普勒：可探測(cè)血流動(dòng)力學(xué)改變

5、，特異性較低 CT與MRI:對(duì)良性DAVF敏感性較低；對(duì)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(duì)瘺口位置及“危險(xiǎn)吻合”顯示欠佳,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,Male,62 tentorial DAVF（Cognard ） The left lateral ICA angiogram shows a tentorial DAVF fed by an inferior marginal tentorial arte

6、ry draining into a cortical vein,L-ICA,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

7、 site of parenchymal hemorrhage,L-ICA,tentorial DAVF（Cognard ）,R-ICA,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(dòng)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）,巖上竇DAVF（Cognard )向脊髓靜脈引流,右腦膜中動(dòng)脈后支，右枕動(dòng)脈腦膜支及右側(cè)腦膜垂體干供血,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,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),介

8、入治療策略,經(jīng)動(dòng)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)動(dòng)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(duì)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,海綿竇DAVF,保守 放療 TAE微粒 TVE TAENBCA,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(duì)側(cè)海綿竇、

9、基底靜脈叢,Spontaneous regression of a cavernous sinus DAVF T2WI 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 resolution of the flow vo

10、ids,L-ECA,Left 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 dural AVFnow drains into the superior ophthalmic vein and the

11、superficial middle cerebral vein .Althoughthe patients symptoms were unchanged, occlusion ofthe DAVF was indicated,TVE of DAVF via an occluded inferior petrosal sinus,L,Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vei

12、n Left CCA angiogram obtained after TVE shows complete occlusion of the DAVF,TVE of DAVF via an occluded inferior petrosal sinus,橫竇乙狀竇DAVF,放療+TAE-微粒,橫竇乙狀竇DAVF,TVE（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),橫竇乙狀竇DAVF,TVE（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,橫竇乙狀竇DAVF,TVE（手術(shù)入路、經(jīng)閉塞靜脈竇

13、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}）,操作難度大，要求技術(shù)高,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. Venograp

14、hy in this parallel channel shows the veins that were draining the fistula,Conversion of an aggressive DAVF to a benign(G3),This 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 pe

15、rsists,Conversion of an aggressive DAVF to a benign(G3),The venous phase 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,難以完全治愈時(shí)，可將侵襲性DAVF轉(zhuǎn)化為良性DAVF,Conversion of an aggressive DAVF to a

16、 benign(G3),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 microca

17、theter that has been advanced via the posterior condylar vein into the affected sinus,Recanalization of a transverse-sigmoid sinus DAVF after TVE,Left 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

18、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 TVE,可能與栓塞不致密有關(guān),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,tentorial dural AVF （Cogna

19、rd 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 months after radiation therapyshows complete obliteration of the tentorial dural AVF,Male,62, present

20、ed with a brain stem hemorrhage The 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,上矢狀竇DAVF,發(fā)

21、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(dòng)脈行靜脈竇栓塞（靜脈竇無正常靜脈引流）,Superior 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 microcath

22、eter 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,前顱窩DAVF,多由雙側(cè)眼動(dòng)脈的篩動(dòng)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(duì)安全，療效好,Anterior fossa dural AVF Unenhanced CT scan shows intracranial hemorrhage at the frontal base Left ICA ang