Clinical Study Of Interventional Embolization For The Treatment Of Cerebral Dural Arteriovenous Fistula

Section one Clinical data analysis of 96 patients with cerebral dural arteriovenous fistulasBackground The concept of dural arteriovenous fistula is the abnormal arteriovenous vascular lesions that occurred in the dura and its appendages—flax and tentorium, accounting for 10-15% of intracranial vascular malformations.The treatment principles of DAVF is occlusion of the fistula completely and permanently to maintain patency of blood vessels. Its therapeutic methods are various and complex, including conservative observation, carotid artery, interventional embolization, surgical resection and radiation therapy. These methods can be used alone or in combination to use. But the conservative observation, carotid artery, surgical resection and radiation therapy with low cure rate, which limits their utilization. In theory, interventional embolization is an ideal method of treatment, because it can use of endovascular approach to directly reach destination and to treat lesions. Many scholars made a lot of work about the basic and clinical research of DAVF, including pathogenesis, clinical type, pathological changes and treatment methods, which made people become more aware of DAVF. In the past 10 years, with the development of interventional neuroradiology, people had deeper knowledge to imaging features and vascular architecture of DAVF. And the development of interventional embolization technology and materials had markedly improved the cure rate.Transarterial and transvenous embolization are the major interventional treatment methods. The choice of the two mathods should be based on the results of DSA which should be contain bilateral internal carotid arteries, external carotid arteries and vertebral arteries, if necessary, including thyrocervical trunk and costocervical trunk. From the angiography, we can confirm the feeding artery and the sites, size and type of the fistula and draining vein and steal phenomenon and dangerous vessels. Regardless of which way by the treatment, we should pay attention to the complication and avoid it.Ideal embolic material should meet the following conditions:1, good biocompatibility; 2, non-toxic and non-carcinogenic and non-teratogenic effect on human; 3, material readily available and not through the X-ray; 4, it can blocking the target vessel permanently; 5 For a variety of different types of delivery microcatheter; 6, it can cause inflammation and damage without thrombosis; 7, embolization is simple and controllable. But in general, different embolic materials each have their own shortcomings. For now, the NBCA glue and Onyx glue are the most common liquid glue embolic materials in clinical. Both can blocking the target fistula permanently and make better effect. But both require surgeons a higher control technology.At the start of interventional Neuroradiology, Our department just began to research the interventional embolization treatment of DAVF, This study summarized clinical experience of interventional embolization for the treatment of DAVF. The result of the study could direct the treatment for interventional embolization of DAVF.Objective The purpose of this part was to summarize the demographic distribution and clinical and morphological characteristics of this group of patients with cerebral DAVFs. This section of study was the basic of section two study.Methods We reviewed and collected the data of 96 cDAVFs patients with complete past history and cerebral angiograms treated in our hospital from January 2000 to January 2011. As to the clinical presentation, we recorded and analysed the basic clinical elements of each patient such as gender, age, head traumatic history and clinical symptom, carefully analyzed each patient's angioarchitectural features, such as the feeding artery and the sites, type of the fistula and draining vein. The data were synthesized and processed with SPSS 13.0 statistical software package. All data were analyzed usingχ2 tests, a P value less than 0.05 was considered to be of statistical significance.Results (1)This group included 96 cerebral DAVFs patients aging from 14 to 64, with an average age at diagnosis of 38.59±14.496, among them,35(35.46%)were male and 61(63.54%)were female.69(71.88%)patients were spontaneous and 27(28.12%)patients with head traumatic history. (2)50 patients with ocular proptosis and chemosis,30 with tinnitus and intracal murmur,19 with aggravating headache and 12 with other presentations such as epilepsy, Vertigo and weakness in the limbs. (3)Among total 305 feeding arteries,186 were ECA system and 76 were ICA system and 43 were VA-BA system. In 96 patients,40's fistulas blood were supplied only with ECA system,8's were supplied only with ICA system,12's were supplied only with VA-BA system,34's were supplied with ECA system and ICA system and 2's were supplied with ECA system and ICA system and VA-BA system.(4)Among total 152 fistulas, male had 55 fistulas and femal had 97 fistulas. As to the area of the fistula,the 152 fistulas were divided into 4 groups. In male patients,20 were cavernous sinus fistulas and 13 were lateral sinus fistulas and 12 was superior sagittalis sinus fistula and 5 were several areas combined and 5 were other areas. In femal patients, the number were 60,13,14,8 and 2. (5)According to Cognard, in 35 male patients, typeⅠwere 8 and typeⅡa were 8 and typeⅡb were 7 and typeⅢwere 6 and type IV were 5 and typeⅤwere 1. In 61 female patients, the number were 16,17,12,9,6 and 1.Conclusions (1) In this group, the proportion of clinical symptom in spontaneous patients and patients with head traumatic history had no statistical significance.(2) In feeding arteries, the arteries of ECA system were the most, even the most fistulas blood were supplied only with ECA system. In EC A system, the MMA were the most feeding arteries.(3)The attack rate of different area had statistical significance in male and female. In female patients, the rate of cavernous sinus fistulas were the highest.(4) The attack rate of different Cognard type had no statistical significance in male and female.Section two Clinical study of interventional embolization for the treatment of cerebral dural arteriovenous fistulaobjective To summarize the methods, technique and complications of interventional embolization for the treatment of DAVF. We evaluated various methods of treatment by the existing clinical data, so as to accumulate clinical experience for the interventional treatment of cerebral dural arteriovenous fistula, enhanced cerebral dural arteriovenous fistula treatment levels and effectiveness.Methods We reviewed and collected the clinical data of interventional embolizaton for 96 cerebral DAVF patients. According to the results of the first part of angioarchitectural features, and we used different materials such as Onyx, NBCA, PVA and GDC for treatment with transarterial or transvenous embolization.61 patients received transarterial embolization and 35 patients received transvenous embolization. If we treated with transvenous embolization, the routh could be the femoral venous to IJV route and the superior ophthalmic vein route. We used angiography immediately after the treatment to evaluate the efficacy. All data were analyzed using Wilcoxon's rank sum test, a P value less than 0.05 was considered to be of statistical significance. All patients were followed for more than 2 months.Results We took transarterial embolizations for 107 fistulas of 61 patients.24 fistulas were embolized by Onyx, among which 2 were additionally embolized with GDC,22 were angiographic disappeared and 2 were partial disappeared with flow reduction.45 fistulas were embolized by NBCA, among which 38 were angiographic disappeared,5 were partial disappeared with flow reduction and the flow had not reduced in 2 fistula.35 fistulas were embolized by PVA, among which 18 were angiographic disappeared,14 were partial disappeared with flow reduction and 3 were not much changed.3 fistulas were partial disappeared with flow reduction by GDC.45 fistulas were treated with transvenous embolization.25 fistulas were embolized by Onyx, among which 6 were additionally embolized with GDC,24 were angiographic disappeared and 1 was partial disappeared with flow reduction.18 fistulas were embolized by NBCA, among which 2 were additionally embolized with GDC,14 were angiographic disappeared,4 were partial disappeared with flow reduction.2 fistulas were embolized by GDC, one was angiographic disappeared, the other was not much changed. The therapeutic effect between the liquid glue and PVA has statistical significance, and the therapeutic effect between the two treatment groups has no statistical significance. All patients were followed for more than 2 months by DSA or phone or outpatient. The DSA follow-up study found that 7 patients's fistulas relapsed, among which 2 patients's clinical symptoms were worse and 5 had not much change, the others were cured. The phone or outpatient follow-up study found that 1 was worse,9 had not much change,62 were cured. No one appear cerebral infarction and cerebral hemorrhage complication.Conclusions (1)Onyx glue can improve the safety and effectiveness of interventional embolization. With the improvement of Solvents and technology, Onyx glue is expected to the first choice of the embolic materials for the interventional embolization of DAVF; (2)The therapeutic effect between the liquid glue and PVA has statistical significance, and the effect of the liquid glue is better; (3)Transarterial and transvenous embolization are the major interventional treatment methods, the therapeutic effect of which has no statistical significance;(4)The embolization of cavernous sinus fistulas via unopacified inferior petrous sinus is effective method. (5)Interventional embolization is effective for DAVF as long as taking correct methods to avoid the risk and complications.