Nishimuta Yosuke, Awa Ryuji, Sugata Sei, Nagayama Tetsuya, Makiuchi Tsuneo, Tomosugi Tetsuzo, Hanaya Ryosuke, Tokimura Hiroshi, Hirano Hirofumi, Moinuddin F M, Kamil Muhammad, Kibe Akari, Arita Kazunori
Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1, Sakuragaoka, Kagoshima, 890-8520, Japan.
Department of Neurosurgery, Kagoshima City Hospital, Kagoshima, Japan.
Acta Neurochir (Wien). 2017 Nov;159(11):2113-2122. doi: 10.1007/s00701-017-3336-4. Epub 2017 Sep 20.
The long-term efficacy of endovascular treatment (EVT) for cavernous sinus dural arteriovenous fistulae (CS-dAVF) was assessed with a special focus on residual shunts after initial EVT.
This retrospective survey included 50 patients who had undergone EVT and were followed for 1 month or longer (median follow-up 56 months).
Common preoperative symptoms were chemosis (78%), extra-ocular motor palsy (72%), exophthalmos (66%), and tinnitus (26%). CS-dAVF were addressed by transvenous embolization (tVE, n = 48), tVE only was used in 43 instances and tVE plus transarterial embolization (tAE) in five. Two patients underwent tAE only. Procedure-related morbidity (brainstem infarction) was recorded in one patient (2%) and transient symptom exacerbation (paradoxical worsening) in 12 patients (24%). Postoperative digital subtraction angiography showed no major retrograde shunt or cortical venous reflux in any of the 50 patients. Anterograde or minor retrograde residual shunt was observed in 17 patients (34%); three of these underwent additional tVE and four had Gamma Knife surgery. The shunt flow disappeared in all 17 patients 12.6 ± 13.4 (mean ± SD) months after initial EVT. At the latest follow-up, 65.7 ± 52.6 months after the initial operation, no shunt flow was observed in any of the 50 patients. None had remaining or newly developed chemosis or tinnitus on follow-up. The rate of persistent cavernous sinus symptoms at the latest follow-up was higher in patients with than without post-procedural paradoxical worsening (5/12, 41.7% vs. 2/38, 5.3%, p = 0.0059 by Fisher's exact test).
Long-term follow-up showed that EVT, especially tVE, is an efficient and safe treatment for CS-dAVF. It resulted in the eventual disappearance of shunt flow. Residual shunt without major retrograde flow or cortical venous reflux can be monitored without additional treatment.
评估血管内治疗（EVT）对海绵窦硬脑膜动静脉瘘（CS-dAVF）的长期疗效，特别关注初次EVT后的残余分流情况。
这项回顾性研究纳入了50例行EVT且随访1个月或更长时间（中位随访时间56个月）的患者。
常见的术前症状包括结膜充血（78%）、眼外肌麻痹（72%）、眼球突出（66%）和耳鸣（26%）。CS-dAVF通过经静脉栓塞术（tVE，n = 48）进行治疗，其中仅采用tVE治疗43例，tVE联合经动脉栓塞术（tAE）治疗5例。2例患者仅接受了tAE。1例患者（2%）出现与手术相关的并发症（脑干梗死），12例患者（24%）出现短暂性症状加重（反常恶化）。术后数字减影血管造影显示，50例患者中均未出现明显的逆行分流或皮质静脉回流。17例患者（34%）观察到顺行或轻微逆行残余分流；其中3例接受了额外的tVE治疗，4例接受了伽玛刀手术。初次EVT后12.6±13.4（均值±标准差）个月，所有17例患者的分流均消失。在初次手术后65.7±52.6个月的最新随访中，50例患者均未观察到分流。随访期间，无一例患者残留或新发结膜充血或耳鸣。在最新随访中，术后出现反常恶化的患者持续性海绵窦症状发生率高于未出现反常恶化的患者（5/12，41.7%对2/38，5.3%，Fisher精确检验p = 0.0059）。
长期随访表明，EVT，尤其是tVE，是治疗CS-dAVF的一种有效且安全的方法。它最终导致分流消失。对于无明显逆行血流或皮质静脉回流的残余分流可进行监测而无需额外治疗。
