【作者】 郭元星；

【导师】 李铁林；

【作者基本信息】 第一军医大学 ， 神经外科， 2004， 博士

【摘要】 第一部分 创伤性颈动脉海绵窦瘘的血管内栓塞治疗及随访结果 目的：探讨和归纳不同部位、不同类型创伤性颈动脉海绵窦瘘(TCCF)的临床表现、影像学特点及治疗方法的选择，总结出不同部位、不同类型TCCF的临床表现、栓塞技术要点、并发症及处理方法，并推广应用于临床，同时建立有自己治疗特点的TCCF病例组。观察TCCF血管内栓塞治疗术后近期及远期效果，了解TCCF栓塞术后临床症状恢复情况，有否复发及复发的原因，以对指导临床治疗及判断预后发挥重要作用。 方法：回顾分析和总结1986年12月～2003年12月我院诊治且病历资料完整的TCCF病例119例，其中男性81例，女性38例，年龄4～67岁(平均30.9岁)；所有患者均行全脑血管造影确诊，在全身肝素化、神经安定麻醉或全麻下，采用Seldinger技术，经股动脉或股静脉插管，先行全脑血管造影，全面了解瘘口的部位、性质、大小、临床分型及脑循环状况等，再用Magic 3 F-1.8 F BDTE导管行血管内栓塞治疗；栓塞材料主要采用法国BALT公司生产的可脱性球囊，必要时加用微弹簧圈、NBCA、PVA颗粒及干冻硬脑膜片等；入路有股动脉-颈内动脉、股静脉-颈内静脉及经眼上静脉入路。随访主要通过患者再次入院、部分电话访问及信访完成;信访以临床问卷调查为主，再次入院患者则行脑血管造影复查及CT、MRA。全部数据用SPSs10.0统计软件处理。 结果:本组患者右侧63例，左侧54例，双侧2例;临床分型为A型112例，C型2例，D型5例;廖口位置C4段81例，CS段19例，C3段17例，C2段2例;1个屡口n3例，双屡口6例;小屡口8例，复杂特殊型矮口4例，宽屡口1例，无特点痰口106例。119例TCCF病人共行128次栓塞，其中In例1次栓塞成功，8例于第一次栓塞后球囊泄漏复发，经再次栓塞治愈，总治愈率100%，颈内动脉通畅率90.8% (108/119);股动脉入路112例，股静脉入路5例，经眼上静脉入路2例;以球囊栓塞屡口101例，以微弹簧圈栓塞13例，球囊并用弹簧圈2例，干冻硬脑膜3例;无严重并发症及死亡。119例TCCF患者自血管内栓塞术后3个月开始寄调查表，调查表未按时回信者则电话随访。共发出调查表119份，收回46份;部分电话随访64例。共获随访110例，失访9例，随访率92.4%。110例患者中，17例术后行了MRA检查，13例进行了颅脑CT检查，均未见异常。6例患者于术后半年行DSA复查，未见复发。 结论:TCCF一般经股动脉一颈内动脉入路用可脱性球囊栓塞廖口，栓塞时球囊应稳步前进，一旦扩充，决不轻易后拉;小廖口TCCF选择微弹簧圈栓塞;若颈内动脉结扎或闭塞，可经静脉入路栓塞疹口。一般情况下TCCF均表现为良性过程，应力争解剖治愈，不可轻易牺牲颈内动脉。正确选择栓塞途径及栓塞材料是手术成功的关键。TCCF血管内栓塞术后随访是必要的，对指导临床治疗及判断预后有重要意义。MRA和TCD因其无创性而成为TCCF病人长期随访的最佳检测手段。 关键词:外伤颈动脉海绵窦屡栓塞治疗球囊可脱性弹簧圈随访第二部分创伤性颈动脉海绵窦痊血管内介入栓塞治疗 l质床效果影响因素分析 目的:研究影响TCCF血管内栓塞治疗临床效果的因素，以进一步指导临床对患者治疗的选择;观测TCCF血管内栓塞的预后结果，形成 一4-理想的对临床治疗有指导意义的TCCF血管内栓塞治疗预案。 方法:对119例TCCF患者的临床资料、治疗方法及随访结果进行统计分析。统计学方法:(1)对两组频率参数进行t或XZ检验;(2)用Logistic回归分析(Logistio Regression)对影响其术后颈内动脉通畅和临床症状恢复的37项可能影响因素做全因素模型及逐步回归模型分析;(3)全部数据用SPSS10.0统计软件处理。 结果:(1)双侧TCCF比较:左侧颈内动脉通畅率为%.3%，右侧79.4%，两者有显著差异(P二0.006)，其余各个方面均无差异。(2)创伤原因与临床分型、屡口的位置、屡口多少、痰口性质、颈内动脉通畅之间无明显关系。(3)伤后临床症状出现的天数与临床效果之间无明显关系。(4)入院天数与患者伤情分级、临床症状的复发有关，入院天数越短，患者伤情越重，临床症状越容易复发(P二0.000)，入院天数与其余临床效果之间无明显关系。(5)侧别、球囊l号和球囊2号3个因素对患者颈内动脉通畅有显著影响。患者左侧的颈内动脉较右侧颈内动脉不易闭塞;使用1号和2号球囊后患者颈内动脉容易闭塞;压迫颈总动脉不利于搏动性突眼的恢复。 结论:(1)侧别、球囊1号和球囊2号是影响TCCF血管内栓塞治疗后颈内动脉通畅的主要因素;3号球囊使用效果好，不易造成颈内动脉阻塞。(2)入院天数与患者伤情分级、临床症状的复发有关，入院天数越短，患者伤情越重，临床症状也越容易复发:(3)搏动性突眼的恢复与压迫颈总动脉有关，压迫颈总动脉不利于搏动性突眼的恢复;(4)左侧颈内动脉通畅率明显高于右侧。更多还原

【Abstract】 Section oneEndovascular embolization for the treatment of traumatic carotid cavernous fistula and the following up results after the procedureObjective To investigate and conclude the clinical representation, imaging findings and the therapeutic methods of endovascular embolization for the treatment of TCCF in various location and clinical types. To summarize the clinical representation, technique, complications and treating methods of endovascular embolization for the treatment of TCCF in various location and clinical types, and apply to clicic, meanwhile establish our characteristic cases group of TCCF. To observe the short-term and the long-term effectiveness after endovascular embolization for the treatment of TCCF, and to handle recovery outcome of patients clinical symptom, whether or not recurrence in clinical symptoms. The results of the study could direct the treatment and determine the prognosis for endovascular embolization of TCCF.Methods 119 patients with TCCF were analyzed retrospectively from December 1986 to December 2003.119 cases of TCCF, male 81 cases, female 38 cases, age from 4 to 67 years old, average 30.9. All patients with TCCFconfirmed by cerebral angiography with Seldinger technique adopted in the puncture of femoral artery under heparinization and neuro-sonacon anaesthesia. When the sites, character, size of the fistula, clinical classification and cerebral circulation condition were confirmed and diagnosed, Magic 3 F-1.8 F BDTE catheters combining with balloon were used to embolize the fistula or the internal carotid artery with co-axial detachable balloon catheter(Balt company, France). Detachable coils, Polyvinyl Alcohol(PVA) and NBCA were used necessary. All patients were punctured by the femoral artery-ICA route, the femoral venous-IJV approache and the superior ophthalmic vein route. Follow-up study was taken among 119 patients with TCCF by readmission, part calls and letters to the patients in clinical questionnaires. During readmission, the patients were repeated angiography, CT and MRA. All the data were statisted with SPSS10.0 statistical software package.Results 119 cases of TCCF, the right TCCF in 63 cases, the left in 54 cases and bilateral in 2 cases. Clinical type: type A in 112 cases, type C in 2 cases and type D in 5 cases. The fistulas were located at the junctions of C4 in 81 cases, C5 in 19, C3 in 17 and C2 in 1. The number of fistula was one in 113 cases, two in 6 cases. The character of fistula was small fistula in 8 cases, unusual or special TCCF in 4 cases, wide-necked fistula in 1 case. 128 procedures for embolizations were done. TCCFs were embolized success-fully at the first time. 8 cases failed because of leaking balloons, and the 8 cases were embolized successful in second attempt. The total success rate was 100%. The rate of internal carotid artery patency was 90.8%(108/119). 112 patients were punctured by femoral artery route, 5 patients by femoral vein route, and 2 patient by the superior ophthalmic vein. For the embolization materials, balloons were used in 101 cases, microcoils used in 13 cases, both materials used in 2 cases, and caul- cerebral dura mater used in 3 cass. There was no perioperative mortality or complication after the procedure. 119 patients with TCCF were followed up after endovascular embolization from 3 months to 14 years. 119 clinical questionnaires weremailed and 46 were answered. The following up cases by call were 64. The total getting patients of following up were 110, missing 9 cases. The rate of following up was 92.4%.17 of 110 had repeated MRA and 13 repeated CT, 6 cases had repeated angiography in six months, no anything finding.Conclusion Generally speaking, the TCCF can be successfully treated by balloons embolization via femoral artery-ICA route. For small fistula, microcoils embolization are better. Embolization can be done by venous approach when the internal carotid artery was ligation without deliberately occluding internal carotid artery. Right choices of the approach and the embolization materials are更多还原