外伤性颈动脉海绵窦瘘的血管内治疗策略

Endovascular strategy for endovascular treatment of traumatic carotid-cavernous sinus fistula

目的根据外伤性颈动脉海绵窦瘘(TCCF)的影像学分型,制定相应的血管内治疗策略。方法自2000年2月至2003年2月我们共收治各型TCCF患者46例,对他们的影像学分型、所采用的栓塞技术及疗效进行回顾性分析。结果Ⅰ型病例:30例行球囊瘘栓塞术,3例行微弹簧圈瘘栓塞术,2例经动脉入路海绵窦闭塞术,1例经岩下窦入路海绵窦闭塞术,1例经面静脉入路海绵窦闭塞术,3例行颈内动脉闭塞术。Ⅱ型病例:经颈外动脉入路海绵窦闭塞术1例,经岩下窦入路海绵窦闭塞术1例,行压颈治疗1例。Ⅲ型病例:3例均分别行双侧球囊瘘口栓塞术。46例患者治疗均获成功,患侧颈内动脉通畅率达94%(43/46)。随访3个月至3年,有2例并发假性动脉瘤形成,1例症状明显行GDC栓塞后治愈,另1例无症状继续随访。本组无死亡及其它并发症。结论经动脉入路可脱性球囊栓塞瘘是治疗TCCF的首选方法;对于球囊无法进入的小瘘口TCCF可选用微弹簧圈栓塞;对动脉入路不能或失败的Ⅰ型及Ⅱ型患者可行静脉入路栓塞瘘口或海绵窦;对上述经动静脉入路栓塞均失败的Ⅰ型患者,才可考虑闭塞颈内动脉。

Objective To summarize the endovascular methods for the treatment of traumatic carotid-cavernous sinus fistulas (TCCF) according to their image-based types. Methods 46 TCCF patients were admitted to our department from February 2000 to February 2003, their image-based types, endovascular embolizatian techniques and outcomes of the treatments were analyzed retrospectively. Results Patients of Type I were treated by the detachable balloon technique in 30 cases, microcoils fistila embolization in 3cases, cavernous sinus embolization in 4 cases (transarterial approach in 2 cases, transvenous approach in 2 cases) and internal carotid artery occlusion in 3 cases. Patients of Type II were treated by cavernous sinus embolization in 2 cases (transarterial approach in 1 case, transvenous approach in 1 case), and carotid artery compression therapy in 1 case. Patients of Type III were treated by bilateral detachable balloon technique in 3 cases. All the 46 cases were cured, the rate of internal carotid artery patency was 94% (43/46). After the embolization, all patients were followed up for 3～36 months, 2 patients had pseudoaneurysms, one of them was embolized by GDC for obvious symptoms, the other asymptomatic pseudoaneurysm was not treated. There was no death or other complication in this group. Conclusion Although the Detachable balloon technique is the first choice of treatment for TCCF, the microcoils is a good alternative treatment when the orifice of the fistula is too small to allow entry of the balloon, and the venous approaches should be used if the transarterial approachs failed for type I or type II patients. The internal carotid artery occlusion can be considered only when all the transarterial and transvenous approachs failed for type I patients.