Melo Neto João Ferreira de, Pelinca da Costa Eduardo E, Pinheiro Junior Nilson, Batista André L, Rodesch Georges, Bracard Serge, Oliveira Antônio G
1Department of Neurosurgery, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal/RN, Brazil.
2Department of Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France.
J Neurosurg. 2020 Nov 13;135(2):440-448. doi: 10.3171/2020.6.JNS20922. Print 2021 Aug 1.
Dural arteriovenous fistulas (DAVFs) are abnormal, acquired arteriovenous connections within the dural leaflets. Their associated symptoms may be mild or severe and are related to the patient's venous anatomy. With the hypothesis that the patient's venous anatomy determines the development of symptoms, the authors aimed to identify which venous anatomy elements are important in the development of major symptoms in patients with a DAVF.
A multicenter study was performed based on the retrospective analysis of cerebral angiographies with systematic assessment of brain drainage pathways (including fistula drainage) in patients over 18 years of age with a single DAVF. The patients were divided into two groups: those with minor (group 1, n = 112) and those with major (group 2, n = 89) symptoms. Group 2 was subdivided into two groups: patients with hemorrhage (group 2a, n = 47) and patients with severe nonhemorrhagic symptoms (group 2b, n = 42).
The prevalence of stenosis in DAVF venous drainage and the identification of tiny anastomoses between venous territories were significantly higher in group 2 (32.6% and 19.1%, respectively) compared with group 1 (2.68% and 5.36%, respectively). Stenosis of DAVF venous drainage was significantly more frequent in group 2a than in group 2b (51.1% vs 11.9%, p < 0.001). Group 2b patients had increased prevalence of shared use of the cerebral main drainage pathway (85.0% vs 53.2%, p = 0.002), the absence of an alternative route (45.0% vs 17.0%, p = 0.004), and the presence of contrast stagnation (62.5% vs 29.8%, p = 0.002) compared with group 2a patients. In patients with high-grade fistulas, the group with major symptoms had increased prevalence of a single draining direction (31.3% vs 8.33%, p = 0.003), stenosis in the draining vein (35.0% vs 6.25%, p = 0.000), the absence of an alternative pathway for brain drainage (31.3% vs 12.5%, p = 0.017), and the presence of contrast stagnation (48.8% vs 22.9%, p = 0.004).
Major symptoms were observed when normal brain tissue venous drainage was impaired by competition with DAVF (predominance in group 2b) or when DAVF venous drainage had anatomical characteristics that hindered drainage, with consequent venous hypertension on the venous side of the DAVF (predominance in group 2a). The same findings were observed when comparing two groups of patients with high-grade lesions: those with major versus those with minor symptoms.
硬脑膜动静脉瘘（DAVF）是硬脑膜小叶内异常的后天性动静脉连接。其相关症状可能轻微或严重，且与患者的静脉解剖结构有关。基于患者静脉解剖结构决定症状发展这一假设，作者旨在确定哪些静脉解剖结构要素在DAVF患者主要症状的发展中起重要作用。
进行了一项多中心研究，该研究基于对18岁以上单发性DAVF患者的脑血管造影进行回顾性分析，并系统评估脑引流途径（包括瘘管引流）。患者分为两组：症状轻微组（第1组，n = 112）和症状严重组（第2组，n = 89）。第2组又细分为两组：出血患者组（第2a组，n = 47）和严重非出血症状患者组（第2b组，n = 42）。
与第1组（分别为2.68%和5.36%）相比，第2组DAVF静脉引流狭窄的发生率以及静脉区域间微小吻合支的识别率显著更高（分别为32.6%和19.1%）。第2a组DAVF静脉引流狭窄的发生率显著高于第2b组（51.1%对11.9%，p < 0.001）。与第2a组患者相比，第2b组患者共用脑主要引流途径的发生率增加（85.0%对53.2%，p = 0.002），无替代途径的发生率增加（45.0%对17.0%，p = 0.004），以及造影剂滞留的发生率增加（62.5%对29.8%，p = 0.002）。在高分级瘘管患者中，主要症状组单一引流方向的发生率增加（31.3%对8.33%，p = 0.003），引流静脉狭窄的发生率增加（35.0%对6.25%，p = 0.000），脑引流无替代途径的发生率增加（31.3%对12.5%，p = 0.017），以及造影剂滞留的发生率增加（48.8%对22.9%，p = 0.004）。
当正常脑组织静脉引流因与DAVF竞争而受损时（第2b组占优势），或当DAVF静脉引流具有阻碍引流的解剖学特征，从而导致DAVF静脉侧出现静脉高压时（第2a组占优势），会观察到主要症状。在比较两组高分级病变患者（主要症状组与轻微症状组）时也观察到了相同的结果。
