硬腦膜動(dòng)靜脈瘺的介入診斷及治療演示文稿

硬腦膜動(dòng)靜脈瘺的介入診斷及治療演示文稿現(xiàn)在是1頁(yè)\一共有54頁(yè)\編輯于星期二優(yōu)選硬腦膜動(dòng)靜脈瘺的介入診斷及治療Ppt現(xiàn)在是2頁(yè)\一共有54頁(yè)\編輯于星期二硬腦膜動(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(jiàn)于任何年齡，成人多見(jiàn)現(xiàn)在是3頁(yè)\一共有54頁(yè)\編輯于星期二硬腦膜動(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現(xiàn)在是4頁(yè)\一共有54頁(yè)\編輯于星期二嬰兒型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)改變現(xiàn)在是5頁(yè)\一共有54頁(yè)\編輯于星期二女，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MRT1WI：上矢狀竇及竇匯巨大流空影，小腦扁桃體下移現(xiàn)在是6頁(yè)\一共有54頁(yè)\編輯于星期二成人型DAVF現(xiàn)在是7頁(yè)\一共有54頁(yè)\編輯于星期二硬腦膜動(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)脈分支現(xiàn)在是8頁(yè)\一共有54頁(yè)\編輯于星期二現(xiàn)在是9頁(yè)\一共有54頁(yè)\編輯于星期二發(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(shuō)“生理性動(dòng)靜脈交通”開(kāi)放：硬腦膜動(dòng)靜脈之間存“生理性動(dòng)靜脈交通”（dormantchannels)或“裂隙樣血管”（crack-likevessels），某些病理狀態(tài)使其開(kāi)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形成現(xiàn)在是10頁(yè)\一共有54頁(yè)\編輯于星期二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(lái)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)合分型現(xiàn)在是11頁(yè)\一共有54頁(yè)\編輯于星期二按靜脈引流方向分型Bordenclassification1Venousdrainagedirectlyintoduralvenoussinusormeningealvein2VenousdrainageintoduralvenoussinuswithCVR3Venousdrainagedirectlyintosubarachnoidveins(CVRonly)CognardclassificationIVenousdrainageintoduralvenoussinuswithantegradeflowIIaVenousdrainageintoduralvenoussinuswithretrogradeflowIIbVenousdrainageintoduralvenoussinuswithantegradeflowandCVRIIa+bVenousdrainageintoduralvenoussinuswithretrogradeflowandCVRIIIVenousdrainagedirectlyintosubarachnoidveins(CVRonly)IVTypeIIIwithvenousectasiasofthedrainingsubarachnoidveinsVVenousdrainageintotheperimedullaryplexusCVR=corticalvenousreflux（可能與靜脈竇閉塞有關(guān)）現(xiàn)在是12頁(yè)\一共有54頁(yè)\編輯于星期二現(xiàn)在是13頁(yè)\一共有54頁(yè)\編輯于星期二現(xiàn)在是14頁(yè)\一共有54頁(yè)\編輯于星期二按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現(xiàn)在是15頁(yè)\一共有54頁(yè)\編輯于星期二臨床表現(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(wú)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Bordentype1CognardtypeI/ⅡaBordentype2/3CognardtypeIIb-Ⅴ皮層靜脈返流（CVR)或深靜脈引流是預(yù)后不良的重要因素現(xiàn)在是16頁(yè)\一共有54頁(yè)\編輯于星期二搏動(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(jiàn)）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)出血頭痛現(xiàn)在是17頁(yè)\一共有54頁(yè)\編輯于星期二診斷經(jīng)顱多普勒：可探測(cè)血流動(dòng)力學(xué)改變，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”顯示欠佳現(xiàn)在是18頁(yè)\一共有54頁(yè)\編輯于星期二診斷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?，F(xiàn)在是19頁(yè)\一共有54頁(yè)\編輯于星期二Male,62tentorial

DAVF（CognardⅣ）TheleftlateralICAangiogramshowsatentorialDAVFfedbyaninferiormarginaltentorialarterydrainingintoacorticalveinL-ICA現(xiàn)在是20頁(yè)\一共有54頁(yè)\編輯于星期二Male,49DAVFofanteriorcranialfossa（CognardⅣ）TheleftlateralinternalcarotidarteriogramdemonstratesaDAVFsuppliedbytheanteriorethmoidalbranchesoftheophthalmicarteryandthedrainingintracranialveinwithafocalaneurysmaldilatationatthesiteofparenchymalhemorrhageL-ICA現(xiàn)在是21頁(yè)\一共有54頁(yè)\編輯于星期二tentorial

DAVF（CognardⅢ）R-ICA現(xiàn)在是22頁(yè)\一共有54頁(yè)\編輯于星期二術(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（CognardⅡa+b）現(xiàn)在是23頁(yè)\一共有54頁(yè)\編輯于星期二巖上竇DAVF（CognardⅤ)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)腦膜垂體干供血現(xiàn)在是24頁(yè)\一共有54頁(yè)\編輯于星期二R－ECA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)膜充血水腫現(xiàn)在是25頁(yè)\一共有54頁(yè)\編輯于星期二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)現(xiàn)在是26頁(yè)\一共有54頁(yè)\編輯于星期二介入治療策略經(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?lèi)夯?；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(guò)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)一步觀察現(xiàn)在是27頁(yè)\一共有54頁(yè)\編輯于星期二海綿竇DAVF保守放療TAE－微粒TVETAE－NBCA現(xiàn)在是28頁(yè)\一共有54頁(yè)\編輯于星期二海綿竇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(guò)）經(jīng)眼上靜脈入路 其它入路：巖上竇、對(duì)側(cè)海綿竇、基底靜脈叢 現(xiàn)在是29頁(yè)\一共有54頁(yè)\編輯于星期二

SpontaneousregressionofacavernoussinusDAVFT2WIimageshowsmultipleflowvoidsintheposteriorcavernoussinusLeftECAangiogramshowsacavernoussinusduralAVFwithposteriordrainageintotheinferiorandsuperiorpetrosalsinusesFollow-upMRimageshowsresolutionoftheflowvoidsL-ECA現(xiàn)在是30頁(yè)\一共有54頁(yè)\編輯于星期二LeftECAangiogramshowsacavernoussinusDAVFdrainingmainlyintotheinferior

petrosalsinusandpterygopharyngealplexusFollow-upangiogramobtained3months

latershowsthattheinferiorpetrosalsinusisoccluded,andtheduralAVF

nowdrainsintothesuperiorophthalmicveinandthesuperficialmiddlecerebralvein.Although

thepatient’ssymptomswereunchanged,occlusionof

theDAVFwasindicatedTVEofDAVFviaanoccludedinferiorpetrosalsinusL現(xiàn)在是31頁(yè)\一共有54頁(yè)\編輯于星期二SuperselectivevenogramshowsthatthetipofthemicrocatheterhasbeenintroducedintotheoutletstothesuperiorophthalmicveinLeftCCAangiogramobtainedafterTVEshowscompleteocclusionoftheDAVFTVEofDAVFviaanoccludedinferiorpetrosalsinus現(xiàn)在是32頁(yè)\一共有54頁(yè)\編輯于星期二橫竇－乙狀竇DAVF放療+TAE-微?，F(xiàn)在是33頁(yè)\一共有54頁(yè)\編輯于星期二橫竇－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)現(xiàn)在是34頁(yè)\一共有54頁(yè)\編輯于星期二橫竇－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，以防再通致腦出血現(xiàn)在是35頁(yè)\一共有54頁(yè)\編輯于星期二橫竇－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}）操作難度大，要求技術(shù)高現(xiàn)在是36頁(yè)\一共有54頁(yè)\編輯于星期二ThelateralleftECAangiogramshowsaDAVFofthetransversesinuswithCVRandocclusionoftheipsilateralsigmoidsinus.Atransvenousapproachviathecontralateraltransversesinusallowedselectivecatheterizationofaparallelchannel.VenographyinthisparallelchannelshowstheveinsthatweredrainingthefistulaConversionofanaggressiveDAVFtoabenign(G3)現(xiàn)在是37頁(yè)\一共有54頁(yè)\編輯于星期二ThisparallelchannelwasembolizedwithacombinationofplatinumcoilsandHydrocoilAcontrolleftECAarteriogramshowsthattheCVRwaseliminated,althoughthefistulapersistsConversionofanaggressiveDAVFtoabenign(G3)現(xiàn)在是38頁(yè)\一共有54頁(yè)\編輯于星期二ThevenousphaseofthelateralCCAangiogramsbeforeandaftertreatment,weseethatthesecorticalveinscanparticipateinthevenousdrainageofthebrainafterdisconnection難以完全治愈時(shí)，可將侵襲性DAVF轉(zhuǎn)化為良性DAVFConversionofanaggressiveDAVFtoabenign(G3)現(xiàn)在是39頁(yè)\一共有54頁(yè)\編輯于星期二EarlyarterialphaseleftCCAangiogramshowsatransverse-sigmoidsinusDAVF.LatearterialphaseleftCCAangiogramshowsthattheleftsigmoidsinusisoccludedandtheduralAVFdrainsmainlyintocorticalveinsandtheposteriorcondylarvein.SuperselectivevenogramshowsamicrocatheterthathasbeenadvancedviatheposteriorcondylarveinintotheaffectedsinusRecanalizationofatransverse-sigmoidsinusDAVFafterTVE現(xiàn)在是40頁(yè)\一共有54頁(yè)\編輯于星期二LeftCCAangiogramobtainedafterTVEshowsdisappearanceoftheAVF.CTscanobtained2monthsafterTVEshowsamassivehemorrhageinthelefttemporallobe.LeftcommoncarotidangiogramshowsrecanalizationoftheduralAVFattheretrogradecorticaldrainageoutletRecanalizationofatransverse-sigmoidsinusDAVFafterTVE可能與栓塞不致密有關(guān)現(xiàn)在是41頁(yè)\一共有54頁(yè)\編輯于星期二小腦幕DAVF只經(jīng)軟腦膜靜脈引流CognardIII/IV，Ⅴ;Borden3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現(xiàn)在是42頁(yè)\一共有54頁(yè)\編輯于星期二TreatmentOptionsforTentorialDuralAVFs

TreatmentOption*

Results※Radiationtherapy

Completeocclusion(50%–60%)※Intervention

●TAEwithn-butyl-2-cyanoacrylate

Completeocclusion(50%–100%)

●TVE

Completeocclusion(90%–100%in

fewcasereports)※Surgery(disconnectionof

Completeocclusion(100%)

leptomeningealvenousdrainage)*SurgeryandTAEwithn-butyl-2-cyanoacrylateareequalintermsofpotentialriskandtechnicaldifficulty;theyaremorepotentiallyriskyandtechnicallydifficultthanradiationtherapyandlesssothanTVE.現(xiàn)在是43頁(yè)\一共有54頁(yè)\編輯于星期二

tentorialduralAVF

（CognardIV）LeftECAangiogramshowsatentorialduralAVF

withleptomeningeal-corticalvenousdrainageandvenousectasiaLateralradiographshowstheplanned

radiationfieldLeftCCAangiogramobtained8monthsafterradiationtherapyshowscompleteobliterationofthetentorialduralAVF現(xiàn)在是44頁(yè)\一共有54頁(yè)\編輯于星期二Male,62,presentedwithabrainstemhemorrhageTheleftICAangiogramshowsaDAVFfedbyaninferiormarginaltentorialarterydrainingintoacorticalvein.Usingatransvenousapproachcatheterizationofthevenouspouchwasfeasible.Coilsweredepositedwithinthecorticalveinandthevenouspouch

現(xiàn)在是45頁(yè)\一共有54頁(yè)\編輯于星期二上矢狀竇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(dòng)脈行靜脈竇栓塞（靜脈竇無(wú)正常靜脈引流）現(xiàn)在是46頁(yè)\一共有54頁(yè)\編輯于星期二TreatmentOptionsforSuperiorSagittalSinusDuralAVFs

TreatmentOption*

Results※RadiationtherapyUnknown※Intervention

●TAEwithparticlesCompleteocclusion(rare)

●TVECompleteocclusion(90%–100%)

●TAEwithn-butyl-2-cyanoacrylateCompleteocclusion(90%–100%)

●TransarterialsinuscatheterizationCompleteocclusion(100%incaseandcoilembolizatioreports)※Surgery(sinusisolationorresection)Completeocclusion(90%–100%)combinedwithintervention*TreatmentoptionsindecreasingorderofpotentialriskandtechnicaldifficultyareTAEwithn-butyl-2-cyanoacrylate,surgery,TVE,andradiationtherapy.現(xiàn)在是47頁(yè)\一共有54頁(yè)\編輯于星期二

SuperiorsagittalsinusduralAVFRightECAangiogramshowsaduralAVFwithcorticalrefluxandocclusionofthesuperiorsagittalsinusRightECAangiogramobtainedduringtransarterialsinusembolizationshowsamicrocatheterthathasbeenadvancedintothesuperiorsagittalsinusviatherightmiddlemeningealarteryRightECAangiogramobtainedafterembolizationshowsobliterationoftheAVF現(xiàn)在是48頁(yè)\一共有54頁(yè)\編輯于星期二前顱窩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CognardIII/IV;Borden3侵襲性DAVF，顱內(nèi)出血風(fēng)險(xiǎn)大外科手術(shù)相對(duì)安全，療效好現(xiàn)在是49頁(yè)\一共有54頁(yè)\編輯于星期二TreatmentOptionsforAnteriorFossaDuralAVFs

TreatmentOption*

Results※RadiationtherapyUnknown※Intervention

●TAEwithn-butyl-2-cyanoacrylateCompleteocclusion(90%–100%inafewcasereports)

●TVEwitharetrograde