摘要
目的研究以出血起病的颅颈交界区动静脉瘘(CCJ AVFs)的血管构筑特点和临床预后。方法回顾性分析首都医科大学宣武医院神经外科2012年1月至2021年12月连续收治的92例以出血起病的CCJ AVFs患者的一般资料、CCJ AVFs的血管构筑特点[AVFs类型、侧别(左侧、右侧、双侧)、瘘口节段(枕骨大孔、颈1节段、颈2节段)、供血动脉(椎动脉硬膜支、神经根动脉、脊髓前动脉、脊髓后动脉等)、引流静脉(硬膜内向上引流、硬膜内向下引流和向硬膜外引流)、伴动脉瘤样结构、伴引流静脉曲张]和治疗情况(治疗方式及围手术期并发症发生情况)及随访资料(预后)等。根据出血就诊时Hunt-Hess分级将所有患者分为低级别(Hunt-Hess分级Ⅰ~Ⅱ级)组与高级别(Hunt-Hess分级Ⅲ~Ⅴ级)组,并依据随访时改良Rankin量表(mRS)评分分为预后良好组(mRS评分<3分)与预后不良组(mRS评分≥3分),对组间一般资料、血管构筑及治疗情况进行比较。采用多因素Logistic回归分析方法分析影响CCJ AVFs患者预后的危险因素。结果92例患者共102个CCJ AVFs,6个(5.9%)瘘口位于枕骨大孔,69个(67.6%)位于颈1节段,27个(26.5%)位于颈2节段。最多见的CCJ AVFs分型为硬膜AVFs,共54个(52.9%)。椎动脉硬膜支为参与AVFs供血比例最高的供血动脉,占比62.0%(57例)。72例(78.3%)伴有硬膜内向上静脉引流,27例(29.3%)伴有硬膜内向下静脉引流,16例(17.4%)伴有向硬膜外静脉引流。除3例(3.3%)选择保守治疗外,其余89例(96.7%)接受显微手术和(或)介入栓塞治疗,包括66例(71.7%)仅接受显微手术治疗,6例(6.5%)仅接受介入栓塞治疗,17例(18.5%)接受了介入栓塞和显微手术治疗。87例(94.6%)临床预后良好。17例(18.5%)在治疗过程中出现并发症。高级别组患者年龄高于低级别组,差异有统计学意义[(57±9)岁比(51±10)岁,P<0.05];两组瘘口节段分布差异有统计学意义(P<0.05),高级别组瘘口节段主要位于颈1节段,而低级别组瘘口节段主要位于颈1和颈2节段;高级别组伴有硬膜内向下静脉引流比例及伴有动脉瘤样结构比例均高于低级别组[分别为50.0%(10/20)比23.6%(17/72),70.0%(14/20)比38.9%(28/72)],伴有向硬膜外静脉引流比例低于低级别组[0比22.2%(16/72)],组间差异均有统计学意义(均P<0.05)。预后不良组发生并发症患者比例高于预后良好组(3/5比14/87),组间差异有统计学意义(P=0.042)。出现并发症是CCJ AVFs患者预后不良的危险因素(RR=3.729,95%CI:1.575~8.826,P=0.042)。结论以出血起病的CCJ AVFs患者起病状态与CCJ AVFs血管构筑相关,绝大多数患者预后良好。避免并发症有利于带来更好预后。
Objective To investigate the angiographic characteristics and prognosis of craniocervical junction arteriovenous fistulas(CCJ AVFs)with hemorrhage onset.Methods The clinical baseline data,angiographic characteristics of CCJ AVFs(AVFs type,side[left,right,bilateral],fistula segment[occipital foramen,cervical segment 1,cervical segment 2],feeding artery[dural branch of vertebral artery,radicular artery,anterior spinal artery,lateral spinal artery,ascending pharyngeal artery,occipital artery,posterior inferior cerebellar artery,and posterior meningeal artery],direction of draining veins[ascending intradural drainage,descending intradural drainage,epidural drainage],with aneurysmal structures,with varix),treatment condition(treatment modalities and perioperative complications)and follow-up information(prognosis)of 92 patients with CCJ AVFs with hemorrhage onset admitted to the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University from January 2012 to December 2021 were retrospectively analyzed.All patients were divided into low-grade(Hunt-Hess gradeⅠ-Ⅱ)group and high-grade(Hunt-Hess gradeⅢ-Ⅴ)group according to the Hunt-Hess grade at the time of hemorrhage treatment.The patients were divided into good prognosis group(modified Rankin scale[mRS]score<3)and poor prognosis group(mRS score≥3)according to the mRS score during follow-up.The clinical baseline data,angiographic characteristics of CCJ AVFs and treatment condition between groups were compared.The multivariate Logistic regression analysis method was applied to analyze the risk factors influencing prognosis of patients with CCJ AVFs.Results All 92 patients had 102 CCJ AVFs,6(5.9%)AVFs were located at the foramen magnum level,69(67.6%)AVFs at the C1 level,and 27(26.5%)AVFs at the C2 level.Most of CCJ AVFs classification was dural AVFs(54[52.9%]).The dural branch of the vertebral artery was the highest proportion of feeder arteries in AVFs,and in 57(62.0%)AVFs.Seventy-two(78.3%)AVFs had intradural superior venous drainage,27(29.3%)AVFs had intradural inferior venous drainage,and 16(17.4%)AVFs had extradural venous drainage.Except for 3(3.3%)patients who chose conservative treatment,the remaining 89(96.7%)patients received microsurgery and/or interventional embolization,66(71.7%)patients were treated by microsurgery,6(6.5%)patients were treated by interventional embolization,and 17(18.5%)were treated by interventional embolization and microsurgery.Eighty-seven(94.6%)patients had good clinical prognosis.Seventeen cases(18.5%)had got complications during the process of treatment.After grouping according to the Hunt-Hess grading at the time of hemorrhage,the patients in the high-grade group were older than those in the low-grade group([57±9]years vs.[51±10]years),and the difference was statistically significant(P<0.05).There was statistical significance in the distribution of fistula segment between the two groups(P<0.05).Fistulas in the high-grade group were mainly located at cervical 1 segment,while those in the low-grade group were mainly located at cervical 1 and cervical 2 segments.The proportion of patients with intradural venous drainage and aneurysmal structure in the high-grade group were higher than those in the low-grade group(50.0%[10/20]vs.23.6%[17/72],70.0%[14/20]vs.38.9%[28/72]).The proportion of patients with epidural venous drainage was lower than that in the low-grade group(0 vs.22.2%[16/72]).The differences between two groups were statistically significant(all P<0.05).After grouping according to the prognosis status of the latest follow-up mRS score,the incidence of complications in the poor prognosis group was higher than that in the good prognosis group(3/5 vs.14/87)and the difference between two groups was statistically significant(P=0.042).Complications are risk factors of poor prognosis in patients with CCJ AVFs(RR,3.729,95%CI 1.575-8.826,P=0.042).Conclusions The onset status of CCJ AVFs patients with hemorrhage onset is associated with the angiographic architecture of CCJ AVFs,and the vast majority of patients have a good prognosis.Avoiding complications is conducive to better prognosis.
作者
马永杰
宋子豪
叶明
何川
胡鹏
孙力泳
张鸿祺
Ma Yongjie;Song Zihao;Ye Ming;He Chuan;Hu Peng;Sun Liyong;Zhang Hongqi(Department of Neurosurgery,Xuanwu Hospital,Capital Medical University,Beijing 100053,China)
出处
《中国脑血管病杂志》
CAS
CSCD
北大核心
2023年第6期365-373,共9页
Chinese Journal of Cerebrovascular Diseases
基金
国家自然科学基金(82101460)。
关键词
动静脉瘘
颅颈交界区
出血
血管构筑
Arteriovenous fistula
Craniocervical junction
Hemorrhage
Angioarchitecture
