Liu James K, Dogan Aclan, Ellegala Dilantha B, Carlson Jonathan, Nesbit Gary M, Barnwell Stanley L, Delashaw Johnny B
Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
J Neurosurg. 2009 May;110(5):913-20. doi: 10.3171/2008.9.JNS08733.
Surgical intervention may be required if endovascular embolization is insufficient to completely obliterate intracranial dural arteriovenous fistulas (DAVFs). The authors report their 14-year experience with 23 patients harboring diverse intracranial DAVFs that required surgical intervention.
Between 1993 and 2007, 23 patients underwent surgery for intracranial DAVFs. The following types of DAVFs were treated: superior petrosal sinus (in 10 patients); parietooccipital (in 3); confluence of sinuses and ethmoidal (in 2 each); and tentorial, falcine, occipital, transverse-sigmoid, superior sagittal, and cavernous sinuses (in 1 patient each). In all cases, the authors' goal was to obliterate the DAVF venous outflow by direct surgical interruption of the leptomeningeal venous drainage. Transarterial embolization was used primarily as an adjunct to decrease flow to the DAVF prior to definitive treatment.
Complete angiographic obliteration of the DAVF was achieved in all cases. There were no complications of venous hypertension, venous infarction, or perioperative death. There were no recurrences and no further clinical events (new hemorrhages or focal neurological deficits) after a mean follow-up of 45 months.
The authors' experience emphasizes the importance of occluding venous outflow to obliterate intracranial DAVFs. Those that drain purely through leptomeningeal veins can be safely obliterated by surgically clipping the arterialized draining vein as it exits the dura. Radical excision of the fistula is not necessary.
如果血管内栓塞不足以完全闭塞颅内硬脑膜动静脉瘘（DAVF），可能需要进行手术干预。作者报告了他们对23例患有各种颅内DAVF且需要手术干预的患者的14年经验。
1993年至2007年间，23例患者接受了颅内DAVF手术。治疗的DAVF类型如下：岩上窦（10例）；顶枕部（3例）；窦汇和筛窦（各2例）；以及小脑幕、大脑镰、枕部、横窦-乙状窦、上矢状窦和海绵窦（各1例）。在所有病例中，作者的目标是通过直接手术切断软脑膜静脉引流来闭塞DAVF的静脉流出道。动脉内栓塞主要用作辅助手段，以在确定性治疗前减少流向DAVF的血流。
所有病例均实现了DAVF的血管造影完全闭塞。没有发生静脉高压、静脉梗死或围手术期死亡等并发症。平均随访45个月后，没有复发，也没有出现进一步的临床事件（新的出血或局灶性神经功能缺损）。
作者的经验强调了闭塞静脉流出道对闭塞颅内DAVF的重要性。那些仅通过软脑膜静脉引流的DAVF，可以在动脉化引流静脉穿出硬脑膜时通过手术夹闭来安全闭塞。不必进行瘘管的根治性切除。
