显微外科手术治疗破裂颅内硬脑膜动静脉瘘:8例回顾性病例系列研究

Microsurgery for ruptured intracranial dural arteriovenous fistula:a retrospective case series of 8 patients

目的探讨破裂颅内硬脑膜动静脉瘘(dural arteriovenous fistula,DAVF)的急诊手术效果。方法回顾性纳入2013年5月至2022年7月在福建医科大学附属南平第一医院神经外科接受显微外科手术治疗的破裂颅内DAVF患者。收集临床、影像学和随访资料,对患者的临床特征、手术方式选择及治疗效果进行总结。结果共纳入8例DAVF患者,年龄11~60岁,平均48岁,男性7例,女性1例。8例患者均以颅内出血发病,表现为头痛、呕吐2例,单纯意识障碍2例,意识障碍合并脑疝3例,意识障碍合并肢体瘫痪1例。瘘口位于颅前窝4例(其中2例合并动脉瘤),颅中窝2例(其中1例合并烟雾病),横窦区1例,矢状窦前1/3区域1例。Cognard分型:Ⅲ型7例,Ⅳ型1例。入院后全部急诊行开颅显微手术清除血肿,其中4例同时行去骨瓣减压术,1例合并烟雾病的患者同时行硬膜翻转并颞肌贴敷,2例合并同部位动脉瘤的患者同时予以动脉瘤夹闭。8例患者术后复查头颅CT显示血肿均清除满意,中线无移位。2周内复查颅脑CT血管造影(CT angiography,CTA)示瘘口消失。7例患者在术后1~12个月内随访,CTA或数字减影血管造影均显示DAVF无复发,2例合并动脉瘤的患者未见动脉瘤残留或复发。所有患者均无新出现的神经系统症状,2例格拉斯哥转归量表评分较出院时增高1分。结论急诊显微手术是治疗破裂颅内DAVF的有效方法,尤其适用于部分部位特殊或合并血肿、脑疝及其他血管病的患者。

Objective To investigate the emergency surgical effect of ruptured intracranial dural arteriovenous fistula(DAVF).Methods Patients with ruptured intracranial DAVF underwent microsurgery in the Department of Neurosurgery,Nanping First Hospital Affiliated to Fujian Medical University from May 2013 to July 2022 were retrospectively included.The clinical,imaging and follow-up data were collected,and the clinical characteristics,selection of surgical methods and treatment effects of patients were summarized.Results A total of 8 patients with DAVF were enrolled.Their age ranged from 11 to 60 years(average,48 years).There were 7 males and 1 female.All 8 patients suffered from intracranial hemorrhage,manifested as headache and vomiting in 2 cases,simple conscious disturbance in 2 cases,conscious disturbance with cerebral hernia in 3 cases,and conscious disturbance with limb paralysis in 1 case.The fistula was located in the anterior fossa in 4 cases(including 2 cases with aneurysms),the middle fossa in 2 cases(including 1 case with moyamoya disease),the transverse sinus in 1 case,and the anterior 1/3 area of the sagittal sinus in 1 case.Cognard classification:7 patients were typeⅢand 1 was typeⅣ.After admission,all patients underwent emergency craniotomy and microsurgery to remove hematoma.Among them,4 patients underwent decompressive craniectomy at the same time,1 patient with moyamoya disease underwent dural turnover and temporalis muscle application at the same time,and 2 patients with aneurysms at the same location were clipped at the same time.Postoperative re-examination of head CT showed that the hematoma was cleared satisfactorily and the midline was no shift in all 8 patients.CT angiography(CTA)showed that the fistula disappeared within 2 weeks.Seven patients were followed up within 1-12 months after operation.CTA or digital subtraction angiography showed no recurrence of DAVF.Two patients with aneurysms did not have residual or recurrent aneurysms.All patients had no new neurological symptoms,and the Glasgow Outcome Scale score in 2 patients increased by 1 compared with that at discharge.Conclusion Emergency microsurgery is an effective method for the treatment of ruptured intracranial DAVF,especially for patients with special parts or complicated hematoma,cerebral hernia,and other vascular diseases.