Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
J Neurosurg. 2017 Jun;126(6):1884-1893. doi: 10.3171/2016.5.JNS16331. Epub 2016 Sep 2.
OBJECTIVE Many small series and technical reports chronicle the evolution of endovascular techniques for cranial dural arteriovenous fistulas (dAVFs) over the past 3 decades, but reports of large patient series are lacking. The authors provide a thorough analysis of clinical and angiographic outcomes across a large patient cohort. METHODS The authors reviewed their endovascular database from January 1996 to September 2015 to identify patients harboring cranial dAVFs who were treated initially with endovascular approaches. They extracted demographic, presentation, angiographic, detailed treatment, and long-term follow-up data, and they evaluated natural history, initial angiographic occlusion, complications, recurrence, and symptomatic resolution rates. RESULTS Across a cohort of 251 patients with 260 distinct dAVFs, the overall initial angiographic occlusion rate was 70%; recurrence or occult residual lesions were seen on subsequent angiography in 3% of cases. The overall complication rate was 8%, with permanent neurological complications occurring in 3% of cases. Among 102 patients with dAVFs without cortical venous reflux, rates of resolution/improvement of pulsatile tinnitus and ocular symptoms were 79% and 78%, respectively. Following the introduction of Onyx during the latter half of the study period, the number of treated dAVFs doubled; the initial angiographic occlusion rate increased significantly from 60% before the use of Onyx to 76% after (p = 0.01). In addition, during the latter period compared with the pre-Onyx period, the rate of dAVFs obliterated via a transarterial-only approach was significantly greater (43% vs 23%, p = 0.002), as was the number of dAVFs obliterated via a single arterial pedicle (29% vs 11%, p = 0.002). CONCLUSIONS Overall, in the Onyx era, the rate of initial angiographic occlusion was approximately 80%, as was the rate of meaningful clinical improvement in tinnitus and/or ocular symptoms after initial endovascular treatment of cranial dAVFs.
过去 30 年来，许多小系列和技术报告详细记载了颅部硬脑膜动静脉瘘（dAVF）血管内治疗技术的演变，但缺乏大型患者系列报告。作者对大量患者队列的临床和血管造影结果进行了全面分析。
作者回顾了 1996 年 1 月至 2015 年 9 月的血管内数据库，以确定最初采用血管内方法治疗的颅部 dAVF 患者。他们提取了人口统计学、表现、血管造影、详细治疗和长期随访数据，并评估了自然病史、初始血管造影闭塞、并发症、复发和症状缓解率。
在 251 例 260 个不同 dAVF 的患者队列中，整体初始血管造影闭塞率为 70%；3%的病例在随后的血管造影中出现复发或隐匿性残留病变。总体并发症发生率为 8%，其中 3%的病例发生永久性神经并发症。在 102 例无皮质静脉反流的 dAVF 患者中，搏动性耳鸣和眼部症状的缓解/改善率分别为 79%和 78%。在研究后期引入 Onyx 后，治疗的 dAVF 数量增加了一倍；使用 Onyx 前初始血管造影闭塞率为 60%，使用后显著增加至 76%（p = 0.01）。此外，与使用 Onyx 前相比，在研究后期，通过单纯动脉途径闭塞的 dAVF 数量显著增加（43%比 23%，p = 0.002），通过单一动脉蒂闭塞的 dAVF 数量也显著增加（29%比 11%，p = 0.002）。
总体而言，在 Onyx 时代，初始血管造影闭塞率约为 80%，最初采用血管内治疗颅部 dAVF 后，耳鸣和/或眼部症状的有意义的临床改善率也约为 80%。
