Hemodynamics And Endovascular Embolization Of Carotid Cavernous Fistula

Objective:To Analyze the features of carotid-cavernous fistula(CCF) with transcranial doppler ultrasound(TCD) and cerebral digital subtraction angiography(DSA)from the perspective of quantitative and pattern focused on the blood hemodynamics mechanics,including spectrum characteristic and blood velocity,by DSA knowing of its fistula and draining veins.Summarize kinds of methods of endovascular embolization in different parts and types of CCF and generalize the ways of treatment,technical points,to evaluate diagnosis and Clinical value of endovascular embolization in CCF with TCD before and after treatment and assas diagnosis meaning of DSA in CCF at the same time the function of endovascular embolization CCF in order to promote the clinical application.Materials and Methods:Retrospective analyze and sumed Up 26 CCFcases with the medical diagnosis and treatment of of complete information from May 2002 to May 2009. 16 male,10 female,aged 8-72 years(average 31.6 years);16 cases 1 day before embolization and 6 cases 1 week after operation doing TCD examination,2MHz probe window measuring the orbital superior ophthalmic vein,SOV and ICA siphon fistula department blood velocity;2MHz by the temporal window the end of the probe measured bilateral ICA,bilateral middle cerebral artery MCA,anterior cerebral artery ACA and posterior cerebral artery PCA blood velocity; detected the bilateral occipital vertebral artery VA and basilar artery BA blood flow;oppression ipsilateral common carotid artery CCA to detect collateral compensatory willis cycle,while understanding of the draining veins and observe the spectrum characteristic.After using the same method to understand the treatment of changes in hemodynamics.Then recorded their average. blood flow velocity mean Vm and dynamic pulse index PI,through the contralateral and ipsilateral,compared preoperative and postoperative CCF obtained with the spectrum characteristics of blood flow velocity.All patients in local anesthesia,nerve stability can not keep pace with the anesthesia or endotracheal intubation under general anesthesia.26 cases inserted the right femoral artery puncture 8F arterial sheath by using Seldinger technique to 0.032inch super slide in the guide wire placed under the guidance of other bends or 5F single-contrast catheter (older patients with bad vascular conditions),can also be directly guided 8FGuiding catheter doing six cerebral vascular DSA,a comprehensive understanding of the location of fistula,size,number and direction of the draining veins of cerebral blood circulation and compensatory and for classification.According to DSA results and analysis of the hemodynamics then to choose suitable approach and treatment of embolization material.Type ACCF usually embolized with detachable balloon,check Bait France flexibility and the integrity of the balloon,then ued 3F Magic-BDTE balloon catheter after complete assembly,the detachable balloon embolization fistula,if necessary, increased with Guglielmi detachable coils GDC,EDC,with hair coil,such as flee coils;B-type with small fistula can be used Guglielmi detachable coil embolization fistula;type C,D CCF can be used 300-500umPVA or Onyx micro-coils in ECA branch near the end fistula,the combination of CCA oppression or stereotactic radiotherapy.More difficult as the complexity of fistula thrombosis and ICA patency can not guarantee that ICA occlusion is an effective way,but only after balloon occlusion of ICA 30min without any clinical symptoms,and good compensatory contralateral angiography confirmed ICA balloon occlusion test negative,in order to implement balloon free,permanent occlusion of ICA.All data processing used SPSS10.0 statistical software,all the parameters are(?)±S,two sets of preoperative and postoperative measurement data using paired t test,respectively,p <0.05 as statistically significant difference.Result:(1)The ICA in CCF Vm(60.80±10.16) cm / s,PI average of 0.50±0.19,the contralateral ICA Vm (38.52±10.53) cm / s,PI to 0.82±0.12,ipsilateral and contralateral ICA compared with the PI, the difference was statistically significant(P <0.05).(2) The ipsilateral ACA Vm(30.10±9.29) cm /s,average PI 0.62±0.17,for the contralateral ACA Vm(60.60±10.4) cm / s,average PI 0.78±0.26,a result affected by ACA steal lesions,flow rate decreased significantly,.Vm on both sides have significant difference(P <0.05),PI was not obvious changed.(3) Ipsilateral MCA, ACA Vm reduced especialy the ACA and with superior ophthalmic vein reversed the direction of blood flow,ipsilateral PCA flow velocity increased.As a result of compensatory PCoA,MCA Vm ipsilateral lower obviously,no statistical significance,and sometimes can be higher than the contralateral.(4) Ipsiiateral CCA compression that significantly reduce the flow rate until the ICA signal disappeared.,as Willis central compensatory role in contralateral ACA,ICA flow rate will be faster to varying degrees,ACA clear that when a serious blood bandit fistula,the contralateral ACA anterior corntaunicating artery through ACoA and the ipsilateral ACA,ICA terminal directly to the fistula flow backward,and the contralateral MCA,PCA,BA and VA bloodflow may double fistula size,degree stealing and ACoA,PCoA vary compensatory performance for increased velocity,normal or even lower,but no clear statistical significance.(5) Preoperative TCD to show the end of ipsilateral ICA blood flow and fistula flow backward in the vein as a result of mixed blood,the cavernous ICA side spectrum above abnormal,irregular,audio noise and a noise, waveform integration envelope was burr-like disorder,and to detect relatively weak with the low volatility of the venous flow signal,at the same time,swirl and turbulence characteristics for the CCF of the performance,TCD showed more lesions stealing Obviously,DSA showed greater fistula.(6) Six caes of embolization TCD review after 1 week,ipsilateral ICA siphon bend, extracranial normal or reduced blood flow velocity,PI increased,SOV abnormal blood flow disappeared,preoperative signs of the disappearance of abnormal venous drainage,normal ophthalmic artery blood flow is complex,the spectrum returned to normal patterns,vascular murmur disappeared six vascular cerebral DSA confirmed that I did not develop fistula.(7) 1 cases consider based on history and symptoms of traumatic CCF(not included in this group), because of financial difficulties are not self-healing imaging line Matas test.26 cases were made by the DSA angiography accurate diagnosis,mainly for the contrast agent from the ICA or ECA branches spilled into the CS,the irregular-shaped dense shadow of death,connected with the SOV, rock on the sinus,petrosal sinus and the expansion of early enhancement tortuous,and the clinoid ICA and the MCA,ACA is not easy filling,and its distal branches can not show clearly that carotid pressure test can be clearly observed that the fistula location,size,number and the collateral circulation through the Willis ring compensatory collateral circumstances.Specific for the ipsilateral.MCA,ACA did not develop in 8 cases(contralateral ICA before the.trigeminal variation,VA contralateral side through the PCoA to the MCA blood in 3 cases,fully compensated by the contralateral ICA blood 5 cases),ACA or MCA autoradiography.18 cases-of non-performing(ACoA congenital lack of one cases,contralateral ICA variation before the 5 cases of trigeminal),good location fistula in 20 cases,6 cases of complex fistulas is more difficult due to show its exact location and oppression CCA line side contralateral ICA contrast,four cases of contrast agent through the ACoA retrograde ICA filling so that more clearly show the fistula,2 cases of contralateral VA retrograde contrast filling ICA through the PCoA clearly shows the location of fistula.I on the right fistula in 14 cases,12 cases of left side;A type 23 cases,B-type 2 cases,D-type 1 cases,the main stem from the ICA pituitary meninges,ECA meningeal artery with the same CS;C2 fistula is located in paragraph 1 cases,C3 paragraph three cases,C4 paragraph 11 cases,C5 paragraph 8 cases,C4 and C5 at the junction of three cases,middle meningeal artery and one cases of the same CS;a fistula in 23 cases,two-two cases of fistula,multi-fistula 1 cases;to SOV as the main drainage vein of 25 cases(96.2%),all the main side;rock the upper and lower sinus drainage were involved in 22 cases,the vein flowing into the brain from 12 cases of straight sinus,venous drainage from the basement eight cases,the cortex from eight cases of venous drainage,the inter-cavernous sinus to the contralateral CS were five cases of drainage.Venous drainage by typing:Ⅰtype 25 cases,Ⅱ-type 22 cases,Ⅲtype 8 cases,Ⅳtype 12 cases,Ⅴtype 2 cases.(8) no deaths in this group,detachable balloon embolization in 16 cases of fistula (61.5%),embolization CS5 cases(19.2%),GDC packing fistula in 3 cases(11.5%),CS1 embolism cases(3.9%),PVA particles ECA artery embolization end,Onyx fistula embolization in 1 case(3.9%),ICA4 detachable balloon occlusion(15.4%),ipsilateral ICA patency rate of 84.6% (22/26),the cure rate was 100%.26 cases by the femoral artery approach endovascular embolization line 27 times,in different time after the disappearance of symptoms and signs,but two cases of patients 1 year vision has yet to resume,to take account of eye symptoms and hospitalization time interval is too long,irreversible retinal ischemia caused by the optic nerve to restore or cause irreversible damage,26 cases showed no complications and death.Of which 18 cases of contact phone and letters and visits patients,six cases of TCD review,confirmed by cerebral DSA had no recurrence of fistula and brain,eye images ischemia.Conclusions:(1) hemodynamic in CCF is a large number of closure in the main carotid artery blood and cerebral hypoperfusion,high flow,the expansion of the draining veins,speed up,steal fistula based the two methods,primarily TCD and DSA.(2) TCD can display dynamic and observable fistula,the proximal and distal blood flow,intracranial stealing,collateral circulation and venous return compensatory manner,the direct evaluation of willis ring cycle,measure arterial blood Vm and PI value,while it is non-invasive,rapid,and easy for clinical diagnosis and treatment to assess the efficacy,provide an objective basis for long-term follow-up.(3)CCF most valuable anatomical, morphological diagnosis is selective cerebral DSA,it can be intuitive,comprehensive,and accurate observation of the anatomical source of feeding arteries,fistula location,size,number of draining veins manner and whether or not steal the remote to find out the situation before and after the traffic circle,time,fully embodies the characteristics of their hemodynamics,angiography and clinical manifestations of deeper understanding of the relationship between the choice of treatment programs in order to further provide a reasonable basis for the correct,accurate pre-operative full DSA of the brain is very important.(4) A most common type CCF,fistula flow,and generally preferred the femoral artery-ICA approach with detachable balloon embolization of fistula or CS, the best choice of the expansion and better compliance latex Bait gold detachble balloon floating and soft good and the Magic-BDTE catheter,according to the size of DSA show fistula balloon suitable choice of models,Intraoperative balloon should be filled if there is not uniform after the forward pull balloon catheter,such as there is a need to be compared with the agents time,the concentration of,contrast agent-filled must be 180mgI/ml.(5) For small fistula of B,C,D type CCF balloon difficult to enter the CS,as a result of better compliance coil,Onyx diffuse,and can choose artery or vein coil approach,Onyx for fistula or CS embolization,PVA particles 300-500um way for arterial fistula embolization have ECA to participate in the formation of C,D type CCF.(6) If a complex fistula embolization more difficult,the affected side appeared completely steal the-traffic circle at the same time before and after a good negative balloon occlusion test may be affected ICA occlusion is a better way.In short:CCF should be cured for anatomy,correct analysis of preoperative cerebral DSA,to choose the correct way to embolization, packing material:is the key to successful surgery.