Robert Thomas, Sylvestre Philippe, Blanc Raphaël, Botta Daniele, Ciccio Gabriele, Smajda Stanislas, Redjem Hocine, Piotin Michel
Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019, Paris, France.
University of Montreal, Montreal, Canada.
Acta Neurochir (Wien). 2017 May;159(5):835-843. doi: 10.1007/s00701-017-3079-2. Epub 2017 Jan 22.
The presence of a cortical venous reflux (CVR) in a carotid-cavernous fistula (CCF) is well described and is considered to be a criterion for urgent treatment. This reflux is often associated with direct/traumatic CCF and the high-flow of the fistula alone explains the reflux. For indirect CCF, the pathophysiology of a CVR is unclear.
All patients treated endovascularly for an indirect CCF with a cortical venous reflux between 2003 and 2015 were included. We retrospectively analysed data focusing on whether venous outflows of the cavernous sinus would opacify or not with the local injection of contrast, in order to locate those that could explain the venous reflux.
Twenty consecutive patients (male/female ratio, 2/3) were included in this series with a mean age of 63 years. All patients presented ocular signs and no patients showed any neurological sign secondary to the CVR. We distinguished four patterns of CVR: in the superficial middle cerebral vein (75%), in the uncal vein (15%), in the superior petrosal vein (5%) and in the inferior petrosal vein (5%). Seventy percent of the cases presented a lack of opacification in more than three venous outflows of the CS involved. Each patient received an endovascular therapy by venous approach with a success rate of 76.9% per embolisation session. Two patients (10%) presented a permanent ocular paresis and two others a transient deficit.
CVR is directly correlated with the thrombosis of multiple venous outflows of the CS. The "non-opacification" of at least three of the CS venous outflows is necessary for the development of CVR. Such thrombosis may be explained by the combination of haemodynamic and inflammatory changes of the venous wall.
颈动脉海绵窦瘘（CCF）中皮质静脉回流（CVR）的存在已有充分描述，被视为紧急治疗的一项标准。这种回流常与直接/外伤性CCF相关，仅瘘管的高流量就能解释这种回流。对于间接性CCF，CVR的病理生理学尚不清楚。
纳入2003年至2015年间接受血管内治疗的伴有皮质静脉回流的间接性CCF患者。我们回顾性分析数据，重点关注海绵窦的静脉流出道在局部注射造影剂时是否显影，以确定那些可解释静脉回流的情况。
本系列纳入了20例连续患者（男/女比例为2/3），平均年龄63岁。所有患者均有眼部体征，无患者因CVR出现任何神经体征。我们区分出四种CVR模式：大脑中浅静脉（75%）、钩静脉（15%）、岩上静脉（5%）和岩下静脉（5%）。70%的病例在涉及的海绵窦三个以上静脉流出道中出现不显影。每位患者均通过静脉途径接受血管内治疗，每次栓塞治疗的成功率为76.9%。2例患者（10%）出现永久性眼肌麻痹，另外2例出现短暂性功能缺损。
CVR与海绵窦多个静脉流出道的血栓形成直接相关。海绵窦至少三个静脉流出道“不显影”是CVR发生的必要条件。这种血栓形成可能由静脉壁的血流动力学和炎症变化共同解释。
