海绵窦区硬脑膜动静脉瘘介入治疗不同入路的安全性及有效性研究

doi:10.3969/j.issn.1673-5765.2024.11.005

摘要/Abstract

摘要： 目的探究海绵窦区硬脑膜动静脉瘘（cavernous sinus dural arteriovenous fistula，CS-DAVF）不同入路介入治疗策略的安全性和效果。
方法检索空军军医大学第二附属医院神经外科血管病中心前瞻性血管病数据库，回顾性分析2013年1月—2022年12月所有尝试介入治疗的CS-DAVF患者的相关资料，包括一般资料、临床症状体征、影像学资料、手术相关信息以及患者预后与转归，并对资料进行汇总和分析。
结果共71例CS-DAVF患者接受介入治疗，其中54例（76.1%）以眼部症状为主，包括视力下降、结膜水肿、眼球突出、活动受限、眼睑下垂等。66例（93.0%）患者成功完成了手术，其中采取静脉入路栓塞40例（60.6%），动脉入路栓塞21例（31.8%），动静脉联合入路栓塞5例（7.6%）。使用弹簧圈联合Onyx胶29例（43.9%），单纯使用Onyx胶36例（54.5%），单纯使用弹簧圈1例（1.5%）。栓塞术后即刻DSA显示达到完全闭塞57例（86.4%），次全闭塞9例（13.6%）。单因素logistic回归分析结果显示，手术入路[校正OR（adjusted OR，aOR）3.854，95%CI 0.821～18.101，P=0.087＜0.1]和Onyx胶联合弹簧圈（aOR 8.282，95%CI 0.972～70.617，P=0.053＜0.1）与治愈率临界相关。19例（28.8%）出现手术相关并发症，其中15例新发眼部症状或眼部症状加重，2例面部感觉异常，2例发生肢体活动的神经功能障碍。单因素logistic回归分析结果显示，手术并发症与各种影响因素无相关性。65例（98.5%）完成1年临床随访，其中19例出现手术相关并发症的患者16例症状完全消失，2例好转，1例失随访，其余患者除1例仍有复视外原有症状均完全消失。40例（60.6%）患者接受了DSA影像随访，均未复发。
结论 CS-DAVF介入治疗中静脉入路相较于动脉入路更具优势，岩下窦入路可作为首选，采用静脉入路和Onyx胶联合弹簧圈栓塞与治愈率临界相关。其疗效是可观的，虽然部分患者出现并发症，但绝大部分患者均为一过性手术并发症，可以获得满意的临床效果。

文章导读： 研究对本中心所有CS-DAVF患者进行连续病例队列回顾性研究，探究介入治疗的不同入路对患者并发症及治愈率的影响，发现静脉入路相较于动脉入路更具优势，岩下窦入路可作为首选，采用静脉入路和Onyx胶联合弹簧圈栓塞与治愈率临界相关。

关键词: 硬脑膜动静脉瘘; 海绵窦; 入路; 介入治疗; 疗效

Abstract: Objective To explore the safety and efficacy of interventional therapy of cavernous sinus dural arteriovenous fistulas (CS-DAVF) with different approaches and strategies.
Methods Retrieve the prospective vascular disease database of the Vascular Disease Center, Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University. Data from all patients with CS-DAVF who attempted interventional therapy from January 2013 to December 2022 were retrospectively analyzed. All information including patients’ general data, clinical symptoms and signs, imaging data, surgical information, and follow-up results were collected. The data was summarized and analyzed.
Results A total of 71 patients with CS-DAVF attempted interventional therapy. Among them, 54 cases (76.1%) presented with ocular symptoms as the main sign, including decreased vision, chemosis, exophthalmos, limited movement, and ptosis. Sixty-six patients (93.0%) successfully completed the operation, with transvenous approach in 40 cases (60.6%), transarterial approach in 21 cases (31.8%), and combined arteriovenous approach in five cases (7.6%). Onyx was combined with coil in 29 cases (43.0%), Onyx alone in 36 cases (54.5%), and coil alone in one case (1.5%). DSA immediately after embolization showed complete occlusion in 57 cases (86.4%) and subtotal occlusion in nine cases (13.6%). Univariate logistic regression analysis showed that surgical approach [adjusted OR (aOR) 3.854, 95%CI 0.821-18.101, P=0.087＜0.1] and Onyx combined with coil (aOR 8.282, 95%CI 0.972-70.617, P=0.053＜0.1) were related to the critical cure rate.
Surgery-related complications occurred in 19 patients (28.8%), among of them, 15 were with new or worsened exist ocular symptoms, two were with facial paresthesia, and two were with neurological dysfunction affecting limb movement. Univariate logistic regression analysis results showed that surgical complications were not correlated with various influencing factors. Sixty-five patients (98.5%) completed one-year clinical follow-up. Among the 19 patients with surgical complications, 16 cases completely disappeared, two cases improved, one case lost follow-up, and the original symptoms of the remaining patients completely disappeared except for one case who still had diplopia. Forty patients (60.6%) were followed up with DSA, and no recurrence was reported.
Conclusions The transvenous approach is more advantageous than the transarterial approach in the interventional therapy of CS-DAVF, and the inferior petrosal sinus approach can be the first choice. The use of transvenous approach and Onyx combined with coil is related to the critical cure rate. The efficacy is considerable. Although some patients have complications, the majority of patients are transient surgical complications, and satisfactory clinical efficacy can be obtained.

Key words: Dural arteriovenous fistula; Cavernous sinus; Approach; Interventional therapy; Efficacy

中图分类号:

杨子舰, 方伟, 赵振伟, 张涛, 罗国强, 邢子非, 刘海涛, 郭星, 邓剑平. 海绵窦区硬脑膜动静脉瘘介入治疗不同入路的安全性及有效性研究[J]. 中国卒中杂志, 2024, 19(11): 1288-1295.

YANG Zijian, FANG Wei, ZHAO Zhenwei, ZHANG Tao, LUO Guoqiang, XING Zifei, LIU Haitao, GUO Xing, DENG Jianping. Safety and Efficacy of Different Approaches for the Interventional Therapy of Cavernous Sinus Dural Arteriovenous Fistula[J]. Chinese Journal of Stroke, 2024, 19(11): 1288-1295.

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