血管造影叠加重建技术在头皮动静脉瘘手术计划中的应用

The application of overlay reconstruction technique of angiography in surgical planning of scalp arteriovenous fistulas

目的探讨血管造影叠加重建技术在头皮动脉瘘手术计划中的应用价值和重建技巧。方法回顾性分析2014年2月至2020年4月苏州大学附属第二医院神经外科收治的头皮动静脉瘘患者的临床资料,手术前均经数字减影血管造影明确诊断,并在XperCT Cereb.Fast HD模式下采集数据(不注射造影剂),然后在三维旋转血管成像(3DRA)模式下注射造影剂并采集数据,采用叠加重建技术清晰显示瘘口周围的供血动脉和引流静脉情况,制定手术计划。实施手术对病灶进行切除或断流。所有患者门诊随访,评估局部切口愈合情况以及有无局部头皮症状复发和头皮坏死。切除的病灶送检常规病理检查,行HE染色后显微镜下观察。结果共纳入头皮动静脉瘘患者5例,男3例,女2例,年龄10~60岁,平均34.2岁。所有患者均表现为局部头皮搏动性肿物,1例局部头皮菲薄。5例患者共有5个头皮动静脉瘘,位于右侧3例,左侧2例。颞浅动脉供血为主4例,耳后动脉供血为主1例。1例由1条动脉供血,3例由2条动脉供血,1例由3条动脉供血。3例为同侧动脉供血,2例为双侧动脉供血。单一瘘口1例,多发瘘口4例。1条静脉引流2例,2条静脉引流2例,3条静脉引流1例。5例患者均一期完成手术,2例完整切除病灶,2例行彻底断流术,1例连同病灶与头皮切除后,采集自体大腿皮肤同期植皮。手术后病理显示均为扩张、充血的血管腔,符合动静脉瘘表现。手术后均愈合良好,随访13~87个月,均无局部头皮症状复发和头皮坏死,其中2例行脑血管造影复查,提示头皮动静脉瘘无复发。结论数字减影血管造影可准确、有效地诊断头皮动静脉瘘,叠加重建技术可准确定位瘘口及其周边的供血动脉、引流静脉,有助于手术计划的制定。

Objective To explore the value and technique details of the overlay reconstruction technique of angiography in surgical planning of scalp arteriovenous fistulas.Methods The clinical data of patients admitted from February 2014 to April 2020 in the Neurosurgical Department of Second Affiliated Hospital of Soochow University with scalp arteriovenous fistulas were analyzed retrospectively.Preoperative angiography was carried out in all patients for diagnosis,and the angiographical data was obtained without injection of the contrast agent by the mode of XperCT Cereb.Fast HD followed by three-dimension rotation angiography(3DRA)with the contrast agent.The overlay reconstruction was achieved for surgical planning to demonstrate feeding arteries and drainage veins surrounding the fistula.Surgeries were conducted by resection or devascularization of the lesion.All patients were followed up in the out-patient clinic to assess the healing and to detect the symptomatic recurrence and scalp necrosis.The pathological changes of the lesion were observed by HE staining.Results Five patients were enrolled in this study,including three males and two females aged from 10 to 60 years old(average 34.2-year-old).Pulsatile mass of local scalp was presented in all patients,one with a thin scalp.Five patients suffered from five scalp arteriovenous fistulas,including three on the right side and two on the left.Feeding arteries mainly originated from the superficial temporal artery were confirmed in four cases,and the posterior auricular artery in one case.Single venous drainage was noted in two cases,as well as multiple drainage veins in three cases.Three lesions were supplied by unilateral feeding arteries,while bilateral feeding arteries supplied the rest lesions.Two fistulas were treated by resection,two were treated by devascularization,and one was treated by resection with skin grafting.One lesion was fed by a single artery,three lesions were fed by two arteries,and one lesion was fed by three arteries.Three lesions were fed by unilateral arteries,and two lesions were fed by bilateral arteries.Single fistula was detected in one lesion and multiple fistulas in four lesions.Single drainage was confirmed in two lesions,doubled drainages in two lesions,and tripledrainages in one lesion.All patients experienced surgical treatment in one stage.Two patients underwent complete resection of the lesion,two with complete devascularization,and one with autologous thigh skin grafting after resection.Postoperative pathological examination demonstrated dilated and congested vascular lumen,which was consistent with arteriovenous fistula.All patients healed well after surgery.With13-87 months follow-up,no recurrence and necrosis were noted.Two were reexamined by cerebral angiography,which showed no recurrence.Conclusions Digital subtraction angiography facilitates the diagnosis of scalp arteriovenous fistula accurately and effectively.The overlay reconstruction technique of angiography is crucial for precise localization of fistula shunt and the surrounding feeders and drainages,which is helpful for surgical planning.