【摘要】 目的探讨前颅窝底硬脑膜动静脉瘘(DAVF)的临床特点及显微手术治疗效果。方法回顾性分析南京军区南京总医院神经外科2008年5月至2018年5月连续收治的21例行经翼点或单侧额下入路前颅窝底DAVF切除术患者的临床及影像资料(CT、CT血管成像、MRI、MR血管成像、DSA),其中出血患者8例,非出血患者13例。根据Cognard分型法对21例患者进行Cognard分型。DAVF位于一侧的患者采用翼点入路显微手术,DAVF靠近中线的患者采用单侧额下入路显微手术。采用格拉斯哥昏迷量表(GCS)评分评估出血患者术前及术后的意识状态。术后定期进行临床及影像学随访。结果 8例出血患者中,脑内出血5例,蛛网膜下腔出血1例,脑内出血合并蛛网膜下腔出血2例,均以自发性颅内出血引起的头痛伴意识不清为首发症状;CognardⅢ型3例,Ⅳ型5例。13例非出血患者中,1例有明确的眼部外伤史并以突眼为首发症状,8例以头晕为首发症状,3例以头痛为首发症状,1例以突眼为首发症状。3例术前头部CT检查仅表现为前颅窝底占位性病变;9例术前头部MRI或MR血管成像检查表现为前颅窝底杂乱增粗的异常血管流空影;6例术前头部CT血管成像检查表现为前颅窝底硬脑膜起源的扩张静脉;17例术前DSA检查示瘘口均位于筛板处,供血动脉为眼动脉发出的筛动脉或颌内动脉的终末支,7例有脑膜中动脉的分支参与供血,引流静脉均为皮质静脉并汇入上矢状窦。4例初期仅完善头部CT检查并误诊,2例误诊为前颅窝底肿瘤,2例误诊为动脉瘤,均在DSA检查后确诊。所有患者术后无明显并发症,临床症状较术前均有不同程度的好转,术后复查DSA均未发现异常的瘘口及迂曲扩张的引流静脉。8例出血患者术后(11±3)d GCS评分示患者的意识状态较术前明显改善[术前、术后分别为:(7±2)、(9±1)分,t=-4.646,P<0.05],其中4例患者术后定期随访无不适主诉及复发。13例非出血患者中5例术后定期随访无不适主诉及复发。结论前颅窝底DAVF有较高的出血倾向和特殊的血管构建形式。显微手术是治疗前颅窝底DAVF安全、有效的方法,对出血患者意识状态的改善非常重要。更多还原

【Abstract】 Objective To investigate the clinical characteristics and microsurgical treatment effect of anterior cranial fossa dural arteriovenous fistula( DAVF). Methods Between May 2008 and May 2018,the clinical and imaging data( CT,CT angiography,MRI,MR angiography,and DSA) of anterior cranial fossa DAVF resection in 2 1 consecutive patients treated via pterion approach or unilateral subfrontal approach at the Department of Neurosurgery,Jinling Hospital,Nanjing University School of Medicine were analyzed retrospectively. Among them,8 were bleeding and 13 were non-bleeding. Cognard typing was performed in 21 patients according to the Cognard types. Pterional approach microsurgery was used for patients with DAVF on one side and unilateral subfrontal approach microsurgery was used for patients with DAVF near the midline. Glasgow coma scale( GCS) score was used to evaluate the pre-and post-operative states of consciousness in patients with bleeding. Clinical and imaging follow-up were performed regularly after procedure. Results Of the 8 bleeding patients,5 were intracerebral hemorrhage,1 was subarachnoid hemorrhage,2 were intracerebral hemorrhage complicated with subarachnoid hemorrhage. Spontaneous intracranial hemorrhage-induced headache with unconsciousness was the initial symptom. Three were Cognard type Ⅲ and 5 Cognard type Ⅳ. Of the 13 non-bleeding patients,1 had a clear history of ocular trauma and the first symptom was exophthalmos,dizziness was the first symptom in 8 cases,headache was the initial symptom in 3 cases,and exophthalmos was the initial symptom in 1 case. Preoperative head CT examination revealed that 3 patients showed space occupying lesions of anterior cranial fossa; the preoperative head MRI or MR angiography of 9 patients showed clutter and thickening abnormal vascular washout effect of anterior cranial fossa; the preoperative head CT angiography of 6 patients revealed the dilated vein from dura mater origin at the anterior cranial fossa; Preoperative DSA examinations of 17 cases showed that the fistulas were all located at the sieve plates. The feeding arteries were the sieved artery from ophthalmic artery or the terminal branches of internal maxillary artery. The branches of the meningeal artery were involved in blood supply in 7 cases,and the drainage veins were all cortical veins and flowed to superior sagittal sinus. Four patients only completed the head CT examinations in the early stage and were misdiagnosed,2 were misdiagnosed as tumors of anterior cranial fossa,2 were misdiagnosed as aneurysms,and all of them were diagnosed after DSA. All patients had no obvious complications after procedure. The clinical symptoms were improved to different degrees compared with before surgery. No abnormal fistulas and tortuous dilated drainage veins were found in DSA examinations after procedure. The GCS scores of 8 bleeding patients at 11 ± 3 d after procedure showed that the state of consciousness was significantly improved compared with before procedure( the preoperative and postoperative scores were 7 ± 2 and 9 ± 1 respectively,t =-4. 646,P < 0. 05). Four of the patients were followed up regularly without uncomfortable complaints and recurrence. Of the 13 nonbleeding patients,5 patients w ere follow ed up regularly w ithout uncom fortable com plaints and recurrence. Conclusions Anterior cranial fossa DAVF has higher bleeding tendency and special vascular architecture. Microsurgery is a safe and effective method for the treatment of anterior cranial fossa DAVF. It is very important to improve the conscious states of bleeding patients.更多还原