Luo Chao-Bao, Chang Feng-Chi, Teng Michael Mu Huo, Lin Chung-Jung, Wang An-Guor, Ting Ta-Wei
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC.
Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
J Chin Med Assoc. 2016 Mar;79(3):152-8. doi: 10.1016/j.jcma.2015.09.001. Epub 2016 Jan 29.
Most cavernous sinus dural arteriovenous fistulas (CSDAVFs) present with benign neuro-ophthalmic symptoms. CSDAVFs manifesting with aggressive neurologic symptoms are rare. The purpose of this study was to analyze the different angioarchitectures of aggressive CSDAVFs and to report our experiences of embolization.
Over the past 10 years, a total of 118 CSDAVFs were managed by embolization. From the databases containing such patient information, nine patients (7.6%) were found to have aggressive CSDAVFs presenting with neurologic deficits. There were seven women and two men, ranging in age from 51 years to 78 years (mean, 66 years). We retrospectively analyzed the angioarchitectures of aggressive CSDAVFs, further reviewing patient and angiographic as well clinical outcomes after embolization.
The cause of clinically aggressive CSDAVFs was insufficient fistula drainage because of occlusion (n = 6) or stenosis (n = 1) of the inferior petrous sinus (IPS) or compartment of IPS-cavernous sinus (n = 2) with fistula flow reflux to the veins of brainstem (n = 7) leading to brainstem ischemia, while two fistula flow reflux to the cortical vein leading to cerebral infarction. Transvenous embolization via IPS to fistula was achieved in one case; six patients underwent transorbital access, while transarterial embolization was performed in two cases. Total fistula occlusion was achieved in eight CSDAVFs. All patients had total (n = 7) or partial (n = 2) resolution of their symptoms gradually within 6 months. One patient undergoing transarterial embolization had limb weakness because of inadvertent pial artery occlusion. Their overall mean clinical follow-up period was 17 months.
Aggressive CSDAVFs are associated with occlusion/stenosis of the IPS or compartment of IPS-cavernous sinus with leptomeningeal reflux. In this limited case series, aggressive CSDAVFs most presented with brainstem ischemia, followed by nonhemorrhagic/hemorrhagic stroke in the cerebrum. Embolization through various access routes is a feasible method to manage these aggressive CSDAVFs, with an acceptable level of periprocedural risks.
大多数海绵窦硬脑膜动静脉瘘（CSDAVF）表现为良性神经眼科症状。表现为侵袭性神经症状的CSDAVF较为罕见。本研究的目的是分析侵袭性CSDAVF的不同血管结构，并报告我们的栓塞经验。
在过去10年中，共有118例CSDAVF接受了栓塞治疗。从包含此类患者信息的数据库中，发现9例（7.6%）患者患有表现为神经功能缺损的侵袭性CSDAVF。其中女性7例，男性2例，年龄从51岁至78岁（平均66岁）。我们回顾性分析了侵袭性CSDAVF的血管结构，进一步复查了栓塞治疗后的患者情况、血管造影结果及临床结局。
临床上侵袭性CSDAVF的病因是岩下窦（IPS）闭塞（n = 6）或狭窄（n = 1），或IPS-海绵窦腔闭塞（n = 2）导致瘘管引流不足，瘘管血流反流至脑干静脉（n = 7），导致脑干缺血，而有2例瘘管血流反流至皮质静脉，导致脑梗死。1例经IPS至瘘管进行了经静脉栓塞；6例患者采用经眶入路，2例进行了经动脉栓塞。8例CSDAVF实现了瘘管完全闭塞。所有患者在6个月内症状全部（n = 7）或部分（n = 2）逐渐缓解。1例接受经动脉栓塞的患者因意外闭塞软脑膜动脉而出现肢体无力。他们的总体平均临床随访期为17个月。
侵袭性CSDAVF与IPS或IPS-海绵窦腔闭塞/狭窄伴软脑膜反流有关。在这个有限的病例系列中，侵袭性CSDAVF最常表现为脑干缺血，其次是大脑非出血性/出血性卒中。通过各种入路进行栓塞是治疗这些侵袭性CSDAVF的一种可行方法，围手术期风险可接受。
