小脑幕脑膜动静脉瘘

小脑幕脑膜动静脉瘘临床上比较少见。由于其一般不与大的静脉窦相通，而主要经软脑膜静脉或皮质静脉引流，常常形成静脉性血管瘤而引起蛛网膜下腔出血或脑出血。对小脑幕动静脉瘘的治疗目前仍存在很多争论。文章对这类脑膜动静脉瘘的临床表现、静脉引流方式、解剖学基础、发生机制和治疗等进行了综述。     

复合手术室内治疗伴静脉曲张的软脑膜动静脉瘘一例并文献复习

颅内软脑膜动静脉瘘为一种十分罕见的脑血管畸形,其由供血动脉、瘘口、引流静脉构成,且动静脉之间无畸形血管团。但由于引流静脉内的高流量特点,汇入引流静脉的正常静脉回流受阻,可导致静脉曲张现象,从而易误诊为颅内动静脉畸形。对软脑膜动静脉瘘保守治疗的病死率较高,建议行外科及血管内治疗,且仅需要消除瘘口,阻断动静脉间血流沟通即可。作者通过报道1例由大脑前动脉供血的软脑膜动静脉瘘的治疗体会,结合国外文献报道,探讨软脑膜动静脉瘘的定义、诊断及治疗。     

天幕区硬脑膜动静脉瘘1例报告并文献复习

颅内血管畸形是一类临床表现复杂的疾病,其中10%~15%为硬脑膜动静脉瘘(dural arteriovenous fistula,DAVF)。硬脑膜动静脉瘘有一条或者多条供血动脉,这些供血动脉可以是硬脑膜动脉,也可以是脑动脉的脑膜支,引流静脉为静脉窦、软脑膜静脉或者脊髓静脉。供血动脉穿     

前颅底硬膜动静脉瘘

前颅底硬膜动静脉瘘较少见,但引起自发性颅内出血的机率较高,手术治疗安全、简便,效果彻底。前颅底硬膜动静脉瘘应纳入自发性颅内出血病因的鉴别诊断。经造影证实有皮质静脉引流或引流静脉呈动脉瘤样扩张者应尽早手术。     

颅颈交界区髓周动静脉瘘患者血管构筑特点及治疗策略分析

目的 探究颅颈交界区髓周动静脉瘘(PAVF)的血管构筑特点及治疗策略。方法 回顾性连续纳入2012年1月至2021年12月于首都医科大学宣武医院神经外科住院诊疗的颅颈交界区动静脉瘘成年患者177例,均经DSA及术中所见确诊。依据颅颈交界区动静脉瘘的分型,将所有患者分为PAVF组(14例)和非PAVF组(163例)。记录并分析两组患者一般资料[性别、年龄、起病症状、住院前改良Rankin量表(mRS)评分]、血管构筑[瘘口节段(枕骨大孔、颈1节段、颈2节段)、动静脉瘘侧别(左、右、双侧)、供血动脉(椎动脉硬膜支、神经根动脉、脊髓前动脉、脊髓侧动脉、咽升动脉、枕动脉、小脑后下动脉、脑膜后动脉、脑膜中动脉)、引流静脉方向(硬膜内向上引流、硬膜内向下引流、向硬膜外引流)、伴动脉瘤样结构、伴引流静脉曲张等]、治疗方式(保守治疗、显微手术、介入栓塞、介入栓塞+显微手术)、并发症(脑脊液漏、颅内感染、肺部感染、脑积水、脑梗死、脊髓梗死、颅神经麻痹、下肢静脉血栓形成、椎动脉闭塞等)、复发、随访(分别于出院后1、3、6、12个月进行临床随访,以出院后1年的mRS评分为最终结果)的差异。mRS评分<...     

前颅底硬膜动静脉瘘

前颅底硬膜动静脉瘘较少见，但引起自发性颅内出血的机率较高，手术治疗安全、简便，效果彻底。前颅底硬膜动静脉瘘应纳入自发性颅内出血病因的鉴别诊断。经造影证实有皮质静脉引流或引流静脉呈动脉瘤样扩张者应尽早手术。     

非Galen静脉脑动静脉瘘

Galen静脉脑动静脉瘘是一种少见的先天性脑血管畸形。表现为脑内动脉与静脉间的直细血管或血管,近瘘口处静脉呈动脉瘤样扩张,引流静脉亦扩张,引流静脉亦扩张回静脉引文复习了近年来的文献资料,就本病的临床表现、病理生理、影像学诊断、鉴别诊断及治疗进行综述。     

骶部硬脊膜动静脉瘘合并枕大孔区硬脑膜动静脉瘘一例

正脊髓硬脊膜动静脉瘘(SDAVF)是一种少见病,系由椎间孔处供应神经根或硬脊膜的细小动脉穿过硬膜时与脊髓引流静脉形成的瘘口所致。硬脑膜动静脉瘘(DAVF)是指发生于硬脑膜动脉与硬脑膜静脉、脑静脉窦及皮质静脉间的异常动静脉吻合。对于慢性起病、脊髓受累表现的中老年患者,如经激素治疗导致其症状加重时,应虑及SDAVF的可能性,观察脊髓腹背侧有无纡曲的血管流空影,如有则须通过脊髓血管造影检查确诊,并给予介入或外科手术治疗。     

经动脉采用Onyx－18胶栓塞颅前窝底硬脑膜动静脉瘘

目的探讨经动脉入路采用Onyx-18胶栓塞颅前窝底硬脑膜动静脉瘘的临床疗效。方法于2004年1月—2009年2月期间,对首都医科大学宣武医院收治的颅前窝底硬脑膜动静脉瘘13例患者（其中男9例,女4例;年龄为36～63岁,平均52岁）应用Onyx-18胶,经动脉进行瘘口及引流静脉栓塞。对其临床资料,包括临床表现、影像学、治疗方法及预后进行回顾性分析。结果①通过单侧眼动脉筛前动脉栓塞8例,通过双侧眼动脉筛前动脉栓塞5例;一次性完全栓塞11例,部分栓塞2例。无严重栓塞并发症。②颈内动脉造影显示,单纯眼动脉筛前动脉供血6例,筛前、筛后动脉供血4例,筛前动脉、筛后动脉、颌内动脉、脑膜中动脉供血3例;异常血流经皮质静脉向上矢状窦汇流9例,伴有向基底静脉汇流3例,合并翼丛面静脉引流1例;引流静脉瘤样扩张或静脉湖形成7例。③术后随访1～48个月,所有病例无再出血及癫痫发作。结论经动脉入路应用Onyx-18胶栓塞颅前窝底硬脑膜动静脉瘘可以获得较好的效果,但疗效及安全性仍需大宗病例和长期随访证实。     

非Galen静脉脑动静脉瘘

非Ｇａｌｅｎ静脉脑动静脉瘘是一种少的先天性脑血管畸形，表现为脑内动脉与静脉间的直接沟通，其间无畸形毛细血管床或血管巢，近瘘口处静脉呈动脉瘤样扩张，引流静脉亦扩张向静脉窄引流。文中复习了近年来的文献资料，就本病的临床表现，病理生理，影像学诊断，鉴别诊断及治疗进行综述。     

Superficial and peripheral vascular malformations. Role of interventional radiology and of embolization]

Embolization plays a major role in the management of arteriovenous malformations and fistulae on one hand, and of venous malformations and cystic lymphangiomas on the other hand. The treatment of arteriovenous fistulae today resorts to a primarily endovascular technique including the insertion under controlled flow of a releasable balloon or of a metallic coil positioned in the area of the fistula. Of course, this is possible only if there is a gap between the arterial and venous pathways. When the vessels are in direct contact, surgery must be preferred. In cases of arteriovenous malformations, embolization currently plays a great role; either it is performed with particles in the immediate preoperative period, two or three days before surgery, or as a definitive curative treatment with a polymerizing substance applied in situ. The use of flexible microcatheters allows penetrating into most of these vascular malformations and scattering polymerizing material all over the shunting areas. This is possible for superficial malformations, as is now performed, for instance, for brain AVMs. This embolization obviously can be contemplated only after a decision to treat these malformations has been made, knowing that they may be silent or acquire an uncontrollable evolution potential. This therefore is a collegial decision. As far as venous hemangiomas and cystic lymphangiomas are concerned, the greatest basic therapeutic means today is direct puncture and the in situ injection of a fibrosing substance under angiographic monitoring: the use of Ethibloc or, failing this, of absolute alcohol, has dramatically transformed the prognosis of these malformations, for which the surgical difficulties are well known (easy rupture, blood that often fails to coagulate, life-long progressive evolution).(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical Improvement of Hepatic Venous Mixing to Resolve Systemic Arterial Hypoxemia Associated with Post-Fontan Pulmonary Arteriovenous Fistulae

Pulmonary arteriovenous fistulae are known to develop in patients who have functional single-ventricle heart disease and interruption of the inferior vena cava with direct hepatic drainage to the heart, in which a bidirectional Glenn shunt is the only source of pulmonary blood flow. The progressive systemic arterial hypoxemia that is associated with pulmonary arteriovenous fistulae can have important clinical consequences. Baffling the hepatic venous return to the pulmonary circulation can alleviate pulmonary arteriovenous fistulae.Herein, we present the case of a 13-year-old patient with modified Fontan anatomy and pulmonary arteriovenous fistulae, in whom redirection of a previously placed hepatic venous-to-right pulmonary artery conduit was required in order to increase systemic arterial oxygen saturation. Revision of the conduit improved mixing of hepatic venous effluent with blood flow from the bidirectional Glenn shunt. Three years after this revision, the patient''s oxygen saturation remained stable at 90%, and his physical activity was markedly improved. We present our rationale for selected redirection of the conduit and discuss other surgical options that can improve hypoxemia that is associated with pulmonary arteriovenous fistulae.Key words: Arteriovenous fistula/physiopathology/surgery, arteriovenous malformations/etiology/surgery, Fontan procedure/adverse effects/methods, heart defects, congenital/surgery, hepatic veins/physiology/surgery, postoperative complications/etiology/physiopathology/surgery, vena cava, inferior/abnormalities/surgery, pulmonary artery/surgery, regional blood flow/physiology, reoperationPulmonary arteriovenous fistula (PAVF) can develop in patients who have undergone placement of a bidirectional Glenn shunt for single-ventricle heart disease that is associated with interruption of the inferior vena cava (IVC) and direct hepatic venous drainage to the heart.^1,2 The progressive systemic arterial hypoxemia that is associated with PAVF can have important clinical manifestations. It has been reported that baffling hepatic venous return to the pulmonary circulation can alleviate PAVF. Here, we present and discuss the case of a 13-year-old modified-Fontan patient with PAVF, in whom redirection of a previously placed hepatic venous-to-right pulmonary artery (PA) conduit was required in order to overcome unfavorable streaming and to increase systemic arterial oxygen saturation levels.     

岩上静脉引流的硬脑膜动静脉瘘诊治分析

目的探讨岩上静脉引流的硬脑膜动静脉瘘的临床表现、影像学特点及治疗方式。方法回顾性连续纳入2013年5月至2014年9月首都医科大学宣武医院神经外科和北京海淀医院神经外科由岩上静脉引流的硬脑膜动静脉瘘患者9例,采用血管内栓塞或显微外科手术治疗,并于手术前后完善MRI、DSA检查,进行改良AminoffLogue量表(ALS)评分。结果 9例患者中6例为男性,3例为女性,均表现不同程度的肢体感觉及运动异常,其中7例伴有排尿和(或)排便障碍,4例患者伴有颅神经功能异常,包括声音嘶哑、饮水呛咳、呃逆、面瘫等;6例接受栓塞治疗,3例接受外科手术,均达到解剖学治愈。术前ALS评分为(6.0±2.7)分,术后3个月为(2.8±1.7)分,治疗前后差异有统计学意义(t=4.816,P0.05)。结论岩上静脉引流的硬脑膜动静脉瘘是一类较为少见的脑血管畸形,病变累及范围广泛,临床表现严重,血管内栓塞治疗和显微外科手术均能获得较为理想的疗效,若血管条件允许,应首选介入栓塞治疗。     

经海绵窦手术治疗海绵窦病变疗效观察(附58例报告)

目的：探讨海绵窦(C)病变的手术疗效、方法及影响肿瘤切除的因素。方法：58例CS病变患者施行经颅手术治疗，其中CS内动静脉瘘(AVF)11例，CS内异物(铅弹)2例，CS肿瘤45例。手术经额颞翼点开颅36例，额颞眶-颧弓开颅14例，幕上幕下联合经岩骨开颅8例；手术入路采用经CS上壁上方入路及经CS外侧壁侧方入路。行肿瘤全切28例，部分及次全切17例；对AVF者用止血海绵填塞CS静脉间隙；对CS内铅弹经Parkinson三角取出。结果：肿瘤全切率为63．2％，次全切及部分切除率为36．8％；9例CS内AVF患者的漏口完全消失，2例漏口部分消失者叉行血管内栓塞治疗；2例C内异物者均取出铅弹。1例脑膜瘤患者术后1周死于脑栓塞，出现动眼及外展神经功能障碍各6例。结论：CS病变手术疗效满意，并发症少。对术后影像学证实有残余肿瘤者，应行放疗或放射外科治疗。影响CS内肿瘤切除的因素主要为肿瘤性质、二次手术或放疗。     

大鼠静脉窦高压后硬脑膜微循环变化的动态观察

目的观察大鼠静脉窦高压后硬脑膜微循环的变化，探讨硬脑膜动静脉瘘发生的机制。方法将110只大鼠随机分成两组：实验组85只，对照组25只。实验组大鼠闭塞其上矢状窦和左侧横窦，同时行右侧颈总动脉和颈外静脉吻合，造成静脉窦高压。然后分别在术后7、14、21、28、40、60、90d取实验组大鼠3只和对照组大鼠1只观察硬脑膜微循环，并计量上矢状窦旁开1mm，分别与上矢状窦平行和垂直的1mm直线上所能观察到的直径≤10μm的血管数目和直径的变化。结果在静脉窦高压7d，大鼠硬脑膜未见血管增生；14d后硬脑膜才出现血管增生。90d后，实验组和对照组血管数目差异无显著性（P〉0．05）。实验组大鼠硬脑膜中可观察到毛细血管网中动静脉直接通道的开放，血液经该通道进入静脉的路径直而短（21d）。第28天时实验组大鼠可观察到动静脉瘘形成，而且其形态和结构与正常动静脉短路类似，但连接的血管增粗，不再是毛细血管。结论静脉窦高压形成初期，硬脑膜血管增生活跃，后期血管增生减弱或消失。从瘘口的位置和结构分析，瘘口很可能是由原来存在的血管薄弱部位逐渐演化而来。     

Pulmonary arteriovenous fistula with bilharzial pulmonary hypertension

Congenital pulmonary arteriovenous fistulae, provided that they are not present in very large numbers, are best managed surgically, and there is no effective alternative management. Where pulmonary arteriovenous fistulae develop as a consequence of pulmonary hypertension it is rational to resect the fistulae if the cause of pulmonary hypertension - for example, mitral stenosis - is correctable. Pulmonary arteriovenous fistula in the presence of unexplained or uncorrectable pulmonary hypertension may be the safety valve on which life depends and should, therefore, not be resected. An example is reported of pulmonary arteriovenous fistula associated with bilharzial pulmonary hypertension in which resection of the fistula resulted in death.     

Pulmonary arteriovenous fistula with bilharzial pulmonary hypertension

Congenital pulmonary arteriovenous fistulae, provided that they are not present in very large numbers, are best managed surgically, and there is no effective alternative management. Where pulmonary arteriovenous fistulae develop as a consequence of pulmonary hypertension it is rational to resect the fistulae if the cause of pulmonary hypertension - for example, mitral stenosis - is correctable. Pulmonary arteriovenous fistula in the presence of unexplained or uncorrectable pulmonary hypertension may be the safety valve on which life depends and should, therefore, not be resected. An example is reported of pulmonary arteriovenous fistula associated with bilharzial pulmonary hypertension in which resection of the fistula resulted in death.     

Contribution of ultrasonography in late maturation of native fistulae for chronic hemodialysis

Early failure of arteriovenous fistulae for chronic hemodialysis can be avoided with early preoperative physical examination and complementary explorations. Nevertheless, insufficient development of the arteriovenous fistula after 3 months remains a frequent problem which is sometimes difficult to manage clinically. Duplex-Doppler is the fundamental exploration allowing distinction between pseudo-retard in maturation and true retard with low flow rate. In the first case, blood flow and venous and arterial caliber are normal but unfavorable anatomic conditions may result in superficialization. In the second case, blood flow is too with a true insufficiency in the venous caliber. An exhaustive exploration of the venous and arterial vessels allows accurate diagnosis of arterial strictures limiting inflow or venous strictures limiting dilatation to a diameter sufficient for puncture (6-7 mm). Different situations may occur: --anastomotic or justa-anastomotic strictures with a normal arterial and venous, suggesting the fistulae should be reoperated (excepting the rare situation resulting from intrinsic compression due to a postoperative hematoma); --focal stricture which generally requires interventional radiology on both the arterial and venous sides; --arterial strictures with diffuse calcification, requiring a new arterial site; --insufficient drainage via the elbow or a small or absent cephalic and/or basilary vein.     

Hepatic Arteriovenous Fistulae: Role of Interventional Radiology

Introduction

Hepatic arterial venous fistulae are abnormal communications between the hepatic artery and portal or hepatic vein and commonly occur either secondary to iatrogenic causes like liver biopsy, transhepatic biliary drainage, transhepatic cholangiogram and surgery, or following mechanical insult like blunt or penetrating trauma. Congenital fistulae are rare. Treatment is warranted as an emergency management or in the development of portal hypertension/heart failure in chronic cases. Both surgical and endovascular occlusion of the fistula can be attempted with the latter carrying low intra and post-procedure morbidity. Endovascular treatment has thus currently emerged as a minimally invasive reliable treatment option in such individuals.

Methods and Results

We describe a short series consisting of four cases of acquired hepatic arterioportal/venous fistulae, which were referred to interventional radiology for endovascular management over the last 2 years. Three patients had arterio-portal communication and one patient had communication between the hepatic artery and middle hepatic vein. Successful embolization through the transarterial route was achieved in all four patients. A brief discussion of these cases is presented along with a relevant review of literature.

Conclusions

Endovascular techniques currently form less invasive and first line treatment options in arterioportal/venous fistulae, surgery being reserved only for unsuccessful embolizations/complex fistulae.