Baltsavias Gerasimos, Roth Peter, Valavanis Anton
Department of Neuroradiology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland,
Neurosurg Rev. 2015 Apr;38(2):273-81; discussion 281. doi: 10.1007/s10143-014-0596-9. Epub 2014 Dec 18.
The commonly used Borden and Cognard classification systems for the prediction of clinical behavior of cranial dural arteriovenous shunts focus on the venous drainage, particularly the presence of leptomeningeal venous drainage, and on the direction of flow, particularly the presence of retrograde flow. In addition, the latter includes ectasia and spinal drainage as criteria of two distinct grades. However, none of the above classifications (a) differentiates direct from exclusive leptomeningeal venous drainage, (b) considers cortical venous congestion as a factor potentially associated with an aggressive clinical course, and (c) anticipates ectasia in shunts with a mixed dural-cortical venous drainage (type 2). In this study, we analyzed the angiographic images of 107 consecutive patients having a cranial dural arteriovenous fistula with leptomeningeal venous drainage, based on a newly developed scheme. This scheme, symbolized with the acronym "DES," groups the dural shunts according to three factors: directness and exclusivity of leptomeningeal venous drainage and signs of venous strain. According to the combination of the three factors, eight different groups were distinguished. All analyzed cases could be assigned to one of these groups. Directness of leptomeningeal venous drainage expresses the exact site of the shunt (bridging vein vs sinus wall), whereas exclusivity expresses venous outlet restrictions. All bridging vein shunts had a direct leptomeningeal venous drainage. Almost all bridging vein shunts and all "isolated" sinus shunts had an exclusive leptomeningeal venous drainage. Venous strain, manifested as ectasia and/or congestion, denotes the decompensation of the cerebral venous system due to the shunt reflux. The comparison of the presented concept with the currently used classifications highlighted the advantages of the former and the weaknesses of the latter.
用于预测颅部硬脑膜动静脉分流临床行为的常用博登（Borden）和科尼亚尔（Cognard）分类系统侧重于静脉引流，尤其是软脑膜静脉引流的存在情况，以及血流方向，尤其是逆流的存在情况。此外，后者将扩张和脊髓引流作为两个不同级别的标准。然而，上述分类均未（a）区分直接软脑膜静脉引流与单纯软脑膜静脉引流，（b）将皮质静脉充血视为可能与侵袭性临床病程相关的因素，以及（c）预测具有硬脑膜 - 皮质混合静脉引流（2型）的分流中的扩张情况。在本研究中，我们基于一种新开发的方案分析了107例连续患有伴有软脑膜静脉引流的颅部硬脑膜动静脉瘘患者的血管造影图像。该方案简称为“DES”，根据三个因素对硬脑膜分流进行分组：软脑膜静脉引流的直接性和单纯性以及静脉张力迹象。根据这三个因素的组合，区分出八个不同的组。所有分析的病例都可归入这些组中的一组。软脑膜静脉引流的直接性表示分流的确切部位（桥静脉与窦壁），而单纯性表示静脉流出受限。所有桥静脉分流均有直接软脑膜静脉引流。几乎所有桥静脉分流和所有“孤立性”窦分流均有单纯软脑膜静脉引流。静脉张力表现为扩张和/或充血，表示由于分流反流导致的脑静脉系统失代偿。将所提出的概念与当前使用的分类进行比较，突出了前者的优点和后者的缺点。
