硬脑膜动静脉瘘的介入诊断及治疗课件

1、硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘（DAVF)发生于硬脑膜及其附属结构如静脉窦、大脑镰、小脑幕上的异常动静脉分流约占颅内动静脉畸形的10%-15%可见于任何年龄，成人多见硬脑膜动静脉瘘的介入诊断及治疗”通过阅读科技书籍，我们能丰富知识，培养逻辑思维能力；硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘（DAVF)发生于硬脑膜及其附属结构如静脉窦、大脑镰、小脑幕上的异常动静脉分流约占颅内动静脉畸形的10%-15%可见于任何年龄，成人多见硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘（DAVF)发生于硬脑

2、膜及其附属结构如静脉窦、硬脑膜动静脉瘘（DAVF)硬脑膜窦畸形伴动静脉瘘新生儿或婴儿，常为巨大囊袋或硬膜湖，与其它窦或大脑静脉以缓流交通，多累及上矢状窦，常伴栓塞、闭锁或一侧颈内静脉球发育低下婴儿型DAVF高流速，高流量，多灶性，表现为大的窦及多发的局部动静脉瘘和大的供血血管，常继发引起皮层软膜分流，直窦常缺如；静脉出口闭塞可引起颅压增高，脑室积水成人型DAVF硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘（DAVF)硬脑膜窦畸形伴动静脉瘘硬脑膜动静脉婴儿型DAVF多支供血动脉静脉窦瘤样扩张梗塞性脑积水直窦缺如骨皮质改变硬脑膜动静脉瘘的介入诊断及治疗婴儿型DAVF多支供血动脉硬脑膜动静脉瘘的介入

3、诊断及治疗女，10岁 进行性脑神经缺失（婴儿型DAVF）CT强化： 上矢状窦扩张，脑皮质钙化，白质变薄MR T1WI：上矢状窦及窦汇巨大流空影，小脑扁桃体下移硬脑膜动静脉瘘的介入诊断及治疗女，10岁 进行性脑神经缺失（婴儿型DAVF）CT强化： 上成人型DAVF硬脑膜动静脉瘘的介入诊断及治疗成人型DAVF硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动脉前颅窝脑膜中动脉前支筛前、后动脉脑膜返动脉蝶腭动脉中颅窝脑膜中/副动脉颈内动脉下外侧干咽升动脉脑膜支后颅窝椎动脉脑膜支脑膜垂体干枕动脉脑膜支脑膜中动脉后支咽升动脉脑膜支大脑后动脉分支小脑上动脉分支小脑下后动脉分支硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动脉前

4、颅窝后颅窝硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗发病机制DAVF与手术、头外伤、感染、硬脑膜窦血栓形成、雌激素等因素有关，但确切发病机制不明两种假说“生理性动静脉交通”开放：硬脑膜动静脉之间存“生理性动静脉交通”（dormant channels)或“裂隙样血管”（crack-like vessels），某些病理状态使其开放，形成DAVF新生血管：某些血管生长因子异常释放促使硬脑膜新生血管形成，致使DAVF形成硬脑膜动静脉瘘的介入诊断及治疗发病机制DAVF与手术、头外伤、感染、硬脑膜窦血栓形成、雌激分型按静脉引流方向分型：与临床表现及预后密切

5、相关按DAVF部位分型：与血供来源及治疗途径密切相关静脉引流方向与病变部位相结合分型硬脑膜动静脉瘘的介入诊断及治疗分型按静脉引流方向分型：与临床表现及预后密切相关硬脑膜动静脉按静脉引流方向分型Borden classification1 Venous drainage directly into dural venous sinus or meningeal vein2 Venous drainage into dural venous sinus with CVR3 Venous drainage directly into subarachnoid veins(CVR only)Cogna

6、rd classificationI Venous drainage into dural venous sinus with antegrade flowIIa Venous drainage into dural venous sinus with retrograde flowIIb Venous drainage into dural venous sinus with antegrade flow and CVRIIa+b Venous drainage into dural venous sinus with retrograde flow and CVRIII Venous dr

7、ainage directly into subarachnoid veins (CVR only)IV Type III with venous ectasias of the draining subarachnoid veinsV Venous drainage into the perimedullary plexusCVR=cortical venous reflux（可能与静脉窦闭塞有关）硬脑膜动静脉瘘的介入诊断及治疗按静脉引流方向分型Borden classification硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的介入诊断及治疗硬脑膜动静脉瘘的

8、介入诊断及治疗按DAVF部位分型海绵窦DAVF横窦乙状窦DAVF小脑幕DAVF上矢状窦DAVF前颅窝DAVF边缘窦DAVF岩上/下窦DAVF舌下神经管DAVF硬脑膜动静脉瘘的介入诊断及治疗按DAVF部位分型海绵窦DAVF硬脑膜动静脉瘘的介入诊断及治临床表现良性DAVF搏动性杂音眼眶充血颅神经麻痹慢性头痛无症状侵袭性DAVF颅内出血颅内高压非出血局部神经缺失血管性痴呆死亡Borden type 1Cognard typeI/aBorden type 2/3Cognard type IIb-皮层静脉返流（CVR)或深静脉引流是预后不良的重要因素硬脑膜动静脉瘘的介入诊断及治疗临床表现良性DAVF侵袭

9、性DAVFBorden type 1搏动性突眼球结膜水肿和充血眶周杂音进行性视力下降颅神经麻痹杂音，耳鸣，头痛眼部症状颅内出血（少见）杂音，耳鸣颅内出血中枢神经缺失头痛颅内出血中枢神经缺失，痴呆颅内出血头痛硬脑膜动静脉瘘的介入诊断及治疗搏动性突眼杂音，耳鸣，头痛杂音，耳鸣头痛颅内出血硬脑膜动静脉诊断经颅多普勒：可探测血流动力学改变，特异性较低CT与MRI:对良性DAVF敏感性较低；对侵袭性DAVF，可显示异常血管，颅内出血，局部占位效应，脑水肿，脑积水，静脉窦血栓形成及颅骨骨质异常等征象CTA与MRA：可清楚显示异常增粗的供血动脉和扩张的引流静脉及静脉窦，对瘘口位置及“危险吻合”显示欠佳硬脑膜

10、动静脉瘘的介入诊断及治疗诊断经颅多普勒：可探测血流动力学改变，特异性较低硬脑膜动静脉诊断DSA供血动脉瘘口位置引流静脉静脉窦扩张与闭塞脑循环异常硬脑膜动静脉瘘的介入诊断及治疗诊断DSA硬脑膜动静脉瘘的介入诊断及治疗 Male,62 tentorial DAVF（Cognard ）The left lateral ICA angiogram shows a tentorial DAVF fed by an inferior marginal tentorial artery draining into a cortical veinL-ICA硬脑膜动静脉瘘的介入诊断及治疗 Male,62 ten

11、torial DAV Male,49 DAVF of anterior cranial fossa （Cognard ）The left lateral internal carotid arteriogram demonstrates a DAVF supplied by the anterior ethmoidal branches of the ophthalmic artery and the draining intracranial vein with a focal aneurysmal dilatation at the site of parenchymal hemorrha

12、geL-ICA硬脑膜动静脉瘘的介入诊断及治疗 Male,49 DAVF of anterior crtentorial DAVF（Cognard ）R-ICA硬脑膜动静脉瘘的介入诊断及治疗tentorial DAVF（Cognard ）R-IC术后1年MR示上矢状窦血栓形成，3年后自感颅内杂音，MR示脑表多发迂曲血管流空影；左侧颈外动脉造影侧位，左侧横窦DAVF伴CVR，同侧乙状窦闭塞 女，37肾移植术后，左横窦DAVF（Cognard a+b）硬脑膜动静脉瘘的介入诊断及治疗术后1年MR示上矢状窦血栓形成，3年后自感颅内杂音，MR示脑岩上窦DAVF（Cognard )向脊髓静脉引流右脑膜中动脉

13、后支，右枕动脉脑膜支及右侧脑膜垂体干供血硬脑膜动静脉瘘的介入诊断及治疗岩上窦DAVF（Cognard )向脊髓静脉引流RECA造影：右侧海绵窦DAVF，引流至眼上静脉及皮层静脉男，58右眼球结膜充血水肿硬脑膜动静脉瘘的介入诊断及治疗RECA造影：右侧海绵窦DAVF，引流至眼上静脉及皮层静脉治疗保守治疗立体定向放射治疗血管内介入治疗外科手术硬脑膜动静脉瘘的介入诊断及治疗治疗保守治疗硬脑膜动静脉瘘的介入诊断及治疗介入治疗策略经动脉微粒栓塞（TAE-微粒）：难以达到完全栓塞，通常用于缓解症状或辅助治疗经静脉弹簧圈栓塞(TVE)：治愈性手段，必须致密栓塞，否则可使症状恶化；可并发静脉壁损伤，颅内出血经

14、动脉NBCA/Onyx栓塞(TAE)：用于复杂DAVF不能通过静脉途径栓塞时，完全栓塞率较高；可造成异位栓塞，对操作技术要求高支架植入：其支撑力可恢复静脉窦正常引流并可封闭位于静脉窦壁上的瘘口；远期效果待进一步观察硬脑膜动静脉瘘的介入诊断及治疗介入治疗策略经动脉微粒栓塞（TAE-微粒）：难以达到完全栓塞海绵窦DAVF保守放疗TAE微粒TVETAENBCA硬脑膜动静脉瘘的介入诊断及治疗海绵窦DAVF保守硬脑膜动静脉瘘的介入诊断及治疗海绵窦DAVF经静脉途径是首选的治愈性的方法经岩下窦入路（闭塞时亦可通过）经眼上静脉入路其它入路：岩上窦、对侧海绵窦、基底静脉丛硬脑膜动静脉瘘的介入诊断及治疗海绵窦D

15、AVF经静脉途径是首选的治愈性的方法硬脑膜动静脉瘘的 Spontaneous regression of a cavernous sinus DAVFT2WI image shows multiple flow voids in the posterior cavernous sinus Left ECA angiogram shows a cavernous sinus dural AVF with posterior drainage into the inferior and superior petrosal sinuses Follow-up MR image shows resol

16、ution of the flow voidsL-ECA硬脑膜动静脉瘘的介入诊断及治疗 Spontaneous regression of aLeft ECA angiogram shows a cavernous sinus DAVF draining mainly into the inferiorpetrosal sinus and pterygopharyngeal plexus Follow-up angiogram obtained 3 monthslater shows that the inferior petrosal sinus is occluded, and the d

17、ural AVFnow drains into the superior ophthalmic vein and the superficial middle cerebral vein .Althoughthe patients symptoms were unchanged, occlusion ofthe DAVF was indicatedTVE of DAVF via an occluded inferior petrosal sinusL硬脑膜动静脉瘘的介入诊断及治疗Left ECA angiogram shows a cavSuperselective venogram show

18、s that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein Left CCA angiogram obtained after TVE shows complete occlusion of the DAVFTVE of DAVF via an occluded inferior petrosal sinus硬脑膜动静脉瘘的介入诊断及治疗Superselective venogram shows 横窦乙状窦DAVF放疗+TAE-微粒硬脑膜动静脉瘘

19、的介入诊断及治疗横窦乙状窦DAVF放疗+TAE-微粒硬脑膜动静脉瘘的介入诊横窦乙状窦DAVFTVE（可先栓塞供血动脉）放疗+TAE-微粒支架植入+TAE-微粒+放疗TVE避免栓塞正常皮层静脉引流系统硬脑膜动静脉瘘的介入诊断及治疗横窦乙状窦DAVFTVE（可先栓塞供血动脉）TVE避免栓塞横窦乙状窦DAVFTVE（可先栓塞供血动脉）支架植入受累静脉窦及返流皮层静脉近端必须致密栓塞，以防再通致脑出血硬脑膜动静脉瘘的介入诊断及治疗横窦乙状窦DAVFTVE（可先栓塞供血动脉）受累静脉窦及返横窦乙状窦DAVFTVE（手术入路、经闭塞静脉窦入路、经皮层静脉入路）TAE-NBCA手术切除（可先栓塞供血动脉）操

20、作难度大，要求技术高硬脑膜动静脉瘘的介入诊断及治疗横窦乙状窦DAVFTVE（手术入路、经闭塞静脉窦入路、经皮The lateral left ECA angiogram shows a DAVF of the transverse sinus with CVR and occlusion of the ipsilateral sigmoid sinus. A transvenous approach via the contralateral transverse sinus allowed selective catheterization of a parallel channel. Ve

21、nography in this parallel channel shows the veins that were draining the fistulaConversion of an aggressive DAVF to a benign(G3) 硬脑膜动静脉瘘的介入诊断及治疗The lateral left ECA angiogramThis parallel channel was embolized with a combination of platinum coils and Hydrocoil A control left ECA arteriogram shows th

22、at the CVR was eliminated, although the fistula persistsConversion of an aggressive DAVF to a benign(G3) 硬脑膜动静脉瘘的介入诊断及治疗This parallel channel was emboThe venous phase of the lateral CCA angiograms before and after treatment, we see that these cortical veins can participate in the venous drainage of

23、the brain after disconnection难以完全治愈时，可将侵袭性DAVF转化为良性DAVFConversion of an aggressive DAVF to a benign(G3) 硬脑膜动静脉瘘的介入诊断及治疗The venous phase of the latera Early arterial phase left CCA angiogram shows a transverse-sigmoid sinus DAVF. Late arterial phase left CCA angiogram shows that the left sigmoid sinu

24、s is occluded and the dural AVF drains mainly into cortical veins and the posterior condylar vein. Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein into the affected sinusRecanalization of a transverse-sigmoid sinus DAVF after TVE硬脑膜动静脉瘘的介入诊断及治疗 Ea

25、rly arterial phase left CCALeft CCA angiogram obtained after TVE shows disappearance of the AVF. CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet Re

26、canalization of a transverse-sigmoid sinus DAVF after TVE可能与栓塞不致密有关硬脑膜动静脉瘘的介入诊断及治疗Left CCA angiogram obtained af小脑幕DAVF只经软脑膜静脉引流Cognard III /IV，; Borden 3侵袭性DAVF，颅内出血风险大治疗难度大老年及一般状况差的患者可考虑放射治疗硬脑膜动静脉瘘的介入诊断及治疗小脑幕DAVF只经软脑膜静脉引流硬脑膜动静脉瘘的介入诊断及治Treatment Options for Tentorial Dural AVFsTreatment Option*Resu

27、lts Radiation therapy Complete occlusion (50%60%) Intervention TAE with n-butyl-2-cyanoacrylate Complete occlusion (50%100%)TVE Complete occlusion (90%100% in few case reports) Surgery (disconnection of Complete occlusion (100%)leptomeningeal venous drainage) *Surgery and TAE with n-butyl-2-cyanoacr

28、ylate are equal in terms of potential risk and technical difficulty; they are more potentially risky and technically difficult than radiation therapy and less so than TVE.硬脑膜动静脉瘘的介入诊断及治疗Treatment Options for Tentoriatentorial dural AVF （Cognard IV）Left ECA angiogram shows a tentorial dural AVFwith l

29、eptomeningeal-cortical venous drainage and venous ectasia Lateral radiograph shows the plannedradiation field Left CCA angiogram obtained 8 months after radiation therapyshows complete obliteration of the tentorial dural AVF硬脑膜动静脉瘘的介入诊断及治疗tentorial dural AVF （Cog Male,62, presented with a brain stem

30、 hemorrhageThe left ICA angiogram shows a DAVF fed by an inferior marginal tentorial artery draining into a cortical vein. Using a transvenous approach catheterization of the venous pouch was feasible. Coils were deposited within the cortical vein and the venous pouch 硬脑膜动静脉瘘的介入诊断及治疗 Male,62, presen

31、ted with a 上矢状窦DAVF发生与上矢状窦血栓形成密切相关经静脉途径栓塞困难，常需经手术入路静脉窦栓塞或手术治疗部分病例（瘘口较大）可经动脉行静脉窦栓塞（静脉窦无正常静脉引流）硬脑膜动静脉瘘的介入诊断及治疗上矢状窦DAVF发生与上矢状窦血栓形成密切相关硬脑膜动静脉瘘Treatment Options for Superior Sagittal Sinus Dural AVFsTreatment Option* Results Radiation therapy Unknown Intervention TAE with particles Complete occlusion (ra

32、re) TVE Complete occlusion (90%100%) TAE with n-butyl-2-cyanoacrylate Complete occlusion (90%100%) Transarterial sinus catheterization Complete occlusion (100% in case and coil embolizatio reports) Surgery (sinus isolation or resection) Complete occlusion (90%100%) combined with intervention *Treatm

33、ent options in decreasing order of potential risk and technical difficulty are TAE with n-butyl-2-cyanoacrylate,surgery, TVE, and radiation therapy.硬脑膜动静脉瘘的介入诊断及治疗Treatment Options for SuperiorSuperior sagittal sinus dural AVF Right ECA angiogram shows a dural AVF with cortical reflux and occlusion

34、of the superior sagittal sinus Right ECA angiogram obtained during transarterial sinus embolization shows a microcatheter that has been advanced into the superior sagittal sinus via the right middle meningeal artery Right ECA angiogram obtained after embolization shows obliteration of the AVF硬脑膜动静脉瘘

35、的介入诊断及治疗Superior sagittal sinus d前颅窝DAVF多由双侧眼动脉的筛动脉供血经软脑膜静脉引流Cognard III /IV; Borden 3侵袭性DAVF，颅内出血风险大外科手术相对安全，疗效好硬脑膜动静脉瘘的介入诊断及治疗前颅窝DAVF多由双侧眼动脉的筛动脉供血硬脑膜动静脉瘘的介入Treatment Options for Anterior Fossa Dural AVFsTreatment Option* ResultsRadiation therapy UnknownIntervention TAE with n-butyl-2-cyanoacrylate

36、 Complete occlusion (90%100% in a few case reports) TVE with a retrograde cortical Complete occlusion (90%100% in venous approach a few case reports)Surgery (disconnection of Complete occlusion (100%)leptomeningeal venous drainage) *TVE and TAE with n-butyl-2-cyanoacrylate are equal in terms of potential risk and technical difficulty; they