经皮血管腔内栓塞治疗外伤性颈内动脉海绵窦瘘

Percutaneous endovascular embolization for traumatic carotid-cavernous fistulas

目的回顾性分析外伤性颈内动脉海绵窦瘘(CCF)经血管内途径栓塞治疗的方法、疗效和并发症的处理。方法25例患者均为外伤后出现不同程度的搏动性患侧突眼等症状,术前常规行CT/CTA或MR/MRA检查,并均经DSA造影证实。20例患者行经颈内动脉途径栓塞治疗,栓塞材料包括可脱球囊和(或)可控脱弹簧圈;2例患者行经眼上静脉途径采用微弹簧圈栓塞治疗;3例患者经颈内动脉途径应用可脱球囊和(或)可控脱弹簧圈栓塞失败后,经颈内动脉途径置入带膜支架成功闭塞瘘口。结果25例患者均为单侧CCF,其中22例为Ⅰ型CCF,3例为Ⅱ型CCF。眼上静脉为主要的扩张引流静脉,其他的静脉引流还有基底静脉、侧裂静脉、眼下静脉、岩上窦、岩下窦以及对侧海绵窦等。术后造影见所有25例患者的患侧颈内动脉均保持通畅。20例经颈内动脉途径栓塞治疗的患者中14例栓塞治疗后瘘口完全闭塞,4例患者瘘口残留,1例术后经压颈试验1周瘘口完全闭塞,另2例患者1个月后再次经颈内动脉途径使用DCS成功栓塞瘘口,仅1例瘘口残留患者术后第2天出现硬膜下出血和颅内高压症状,后转入神经外科行开颅减压和结扎止血治疗。2例患者术后2个月复发,再次经颈内动脉途径采用可脱微弹簧圈栓塞后瘘口完全闭塞。2例患者行经眼上静脉途径应用弹簧圈栓塞治疗,其中1例患者栓塞后瘘口少量残留,1个月后再次经颈内动脉途径使用可控脱微弹簧圈(DCS)成功栓塞瘘口。3例患者经颈内动脉途径带膜支架植入术治疗,CCF瘘口完全闭塞。术后造影见所有25例患者的患侧颈内动脉均保持通畅。结论经血管腔内栓塞治疗颈内动脉海绵窦瘘具有创伤小、疗效可靠和可重复操作的特点,是目前治疗CCF的首选方法:及时、有效地处理术后复发可避免严重并发症的发生。

Objective To retrospectively analyze the methods, efficacies and complications for traumatic carotid-cavernous fistulas （CCFs） by endovascular embolization. Methods Symptoms like affected side pulsating exophthalmos etc of varying degrees occurred to all the 25 cases following trauma. Preoperative routine CT/CTA or MR/MKA examinations were performed and all the cases had been confirmed by digital subtraction angiography （DSA）. Embolization treatment was performed on 20 cases via the internal carotid artery （ICA）, materials including detachable balloons and/or microcoils; embolization treatment was performed on 2 cases via the superior ophthalmic vein with microcoils, fistulas were successfully occluded with the implantation of a covered stent via the ICA in 3 cases who had undergone embolization with detachable balloons and/or microcoils via the ICA and the treatment failed in these cases. Results The 25 cases suffering from unilateral CCF included 22 cases of type I CCF and 3 cases of type Ⅱ CCF. The superior ophthalmic vein is the primary dilated draining vein and other venous drainage included the basal vein, sylvian vein, inferior ophthalmic vein, superior petrosal sinus, inferior petrosal sinus and contralateral cavernous sinus etc. Postoperative angiography found that the affected side ICA of all the 25 cases was kept unobstructed. Among the 20 cases undergoing ICA embolization with detachable balloons and/or microcoils, fistulas of lg cases were successfully blocked after endovascular embolization while residual fistulas were found in g cases, fistulas of 1 case were totally blocked 1 week after the Matas test, fistulas of another 2 were absolutely blocked 1 month after the second embolization with the detachable coil system （DCS） through the ICA and postoperative subdural hemorrhage and intracranial hypertension occurred in only ! case with residual fistulas at the second day, who were transferred to Department of Neurosurgery to undergo decompression with craniotomy and hemostasis by arterial ligation. Two cases recurred two months later after embolization, but their fistulas were completely obstructed after embolization with detachable microcoils through the ICA. Two cases underwent embolization through the superior ophthalmic vein with microcoils, among which 1 case recurred due to residual fistulas, but these fistulas were fully blocked with the second embolization with detachable microcoils through the ICA. CCFs were occluded absolutely by covered stent placement through the ICA in 3 cases whose embolization treatment with detachable balloons and microcoils failed. Postoperative angiography found that the affected side ICA of all the 25 cases became unobstructed. Conclusion Endovascular embolization with detachable balloons and/or microcoils is a microinvasive, reliable, effective and repeatable therapy for CCFs of the ICA, so it is the method of first choice for the treatment of CCFs. Serious complications can be avoided by prompt and effective treatment of postoperative recurrences.