The Clinical Therapeutic Strategy For Dural Arteriovenous Fistula (the Report Of 10 Cases)

Dural arteriovenous fistula(DAVF)is a kind of vascular pathological changes, which has an abnormal arteriovenous shunt happened on cerebral Dura mater, cerebral falx, tentorium of cerebellum and venous sinus. The clinical manifestation depends on the size and the position of the draining vein. It comes to be one of the puzzles for neurosurgery; because of the microsurgery have a high recurrence rate and much complication, and also the lack of the embolism material. Of course, the endovascular treatment was fallen behind. In recent years, alone with the development of the microsurgery and endovascular treatment, and the improvement of the embolism material, the success ratio of the treatment has a sharp raise. The purpose of the treatment also gradually transits from"Block the fistula completely and enduringly"to"Improve the quality of life of the patients", and does not pursue the"Iconography Cure"as usual. The neurosurgery of our hospital diagnosed a couple of patients by DSA from 2008; ten of them had the endovascular treatment. As the exploration in the process of the treatment, we sum up the experience, and have the substantial basis for the cure of this disease, and make sure the patients will have the best effect of the treatment. This passage is mainly discussing form the way we choose of the microsurgery or endovascular treatment, and the reasonable experiment of Stereotactic Radiation Therapy and so on.Objective: To investigate the the choice of microsurgery or the endovascular treatment and the clinical application of the Stereotactic Radiation Therapy for a DAVF patient. Datas and Methods: The retrospectively review of the medical records of 10 patients with DAVF, which was treated at our institution with the surgery, form January 2008 to December 2010, Among them , 7 patients were men and 3 were women. The ages of the patients in this study ranged from 19 to 57 years old, the average age is 40.6 years old, and the median age is 42. The pathogenesis in this study were ranged from 2 days to 3 years, the average pathogenesis is 20 days. The patient were hospitalized ranged from 9 to 32 days, the average of it is 19.2 days. Signs and symptoms at presentation were, Headache(n=5), Eyes swelling with exophthalmos (n=3), Headache with exophthalmos (n=1), tinnitus with exophthalmos (n=1), All the patients have the symptoms of the intracranial noise, and neither of them has the injury history in the near future.All the patients had a CT scan on head and DSA examine to definitude the position and the size of the fistula, also the situation of feeding artery and draining vein. With the judgment, it's fit for the endovascular treatment. According to the Type of Cognard, IIa type have 5 cases, IIb type have 1 case, IIa+b type have 1 case, III type have 2 cases , IV type have 1 case. As the comprehensive assessment, 8 cases got the way of femoral artery approach , and 2 cases used the femoral vein approach. With the guidance of synchro, we transported the micro catheter to the feeding artery or the draining vein near the fistula, using various embolic materials to block the fistula, and have examine of DSA sometimes to estimate the situation. Case 6 and Case 9 could see the high blood velocity, and make the plan to block part of the fistula by some solid state embolization and then use the liquid state embolization agents. Case 4 has the DAVF with an right posterior communicants aneurysm, we made the plan of embolizing the aneurysm in the same time. Case 8 had the queckenstedt test for 3 months and the DAVF hadn't been self-healing, so we should use the vein approach DAVF embolization.Results: All patients have got the DSA to definitude whether the embolization is complete, or it's fit or not to continual embolize. 10 cases hadn't got the complication of vascular injury, Intracranial Hemorrhage, neither the embolization accidently, cranial nerve damage nor the loss of nerve functions. 1 case have a numb on the face, 1 case have been awake for a time, nearly 3 hours past, the patient had got an unconsciousness, then a breath arrest had happened, with 1 hour's rescue, the family member gave up the plan of treatment. 3 cases had a subtotal embolization, because of the pursuing of the completely embolization could lead to a sharp nervous syndrome. Other cases were got an"Iconography cure"and also got a cure of the clinical symptoms.The follow up of these patients are range to 3 months to 24 months. The number of completely cure is 6, subtotal one is 3, and partly one is 1. Case 4 had given up the treatment, and the tele-follow up affirm that she is dead. Case 5 and 7 had a review of DSA at the 6 months and the 12 months after the treatment, and the fistula is gone. Case 10 had a review of DSA, the fistula had no changes, so did the draining vein. And the symptoms were all gone, so the curative effect is fantastic, but we still need to follow up. Other cases haven't seen any recurrence in 3 months to 2 years.Conclusion:â‘ With the change of medicine model, The purpose of the DAVF treatment gradually transits from"Block the fistula completely and enduringly"to"Improve the quality of life of the patients". With this precondition, it would be have a perfect curative effect if we don't appeal the"Iconography cure".â‘¡According to the type of the Cognard, we could confirm the operative technique approximately, but still need case by case.â‘¢The therapeutic schedule of DAVF should not be a stickler of a kind of surgical approach, the auxiliary means and the joint of the surgery is also helpful in particular-case.â‘£It would be a great curative effect with the multi-cultural and individual therapeutic schedule for a patient of DAVF.