Clinical Research Of Dural Arteriovenous Fistula On The Etiological Factor And Endovascular Treatment

Dural arteriovenous fistula (dural arteriovenous fistula, DAVF) is a vascular disease with directed arteries and veins communication, involving in the dura and its appendages (venous sinus, cerebral falx and tentorium of cerebellum), which accounting for10%-15%of intracranial arteriovenous malformation. The etiology and pathogenesis for DAVF are not clear yet, and it may develop into fatal intracranial bleeding or cerebral hernia in the end. Furthermore, because of the complex angioarchitecture, it is difficult to treat a DAVF. Therefore, we mainly focus on the risk factors for the generation and aggressive development of the DAVF, as well as evaluating its treatment method and the curative effect.The First ChapterAnalysis of Risk Factors of Dural Arteriovenous FistulaBackgroundIt is still unclear that the cause for the generation of dural arteriovenous fistula (DAVF); there may be relation with factors as follows:factors affecting blood vessel physiology, sinus venosus anatomic structure, and the change of haemodynamics. Though literature reported that DAVF usually coexists with the sinus thrombosis, trauma, brain tumors, the reducing of female hormone, age and so on, but till now they are limited in clinical case report but lack of system analysis.ObjectiveTo study the risk factors for the DAVFMethods146patients in DAVF group were selected from southern medical university zhujiang hospital in the near10years, male56cases, female90cases, age range from14to76years, and134cases in control group with a normal cerebral angiography in the same period, male68cases, female66cases, age range from2to71years. The differences between the two groups were analyzed, including age, sex, hypertension, hyperlipemia, hypertension, smoking, tumor, trauma, transverses-sigmoid sinus asymmetry, pregnancy and sinus thrombosis, and then the logistic regression analysis method was used to analyze the above factors which having significant difference to find the risk factors for the DAVF.ResultsThere are significant differences between the patient group and the control group in age (42.4±15.7years,35.3±18.1years; P=0.000), female (61.6%,49.3%, P=0.037), sinus thrombosis (15.8%,1.5%; P=0.000), head trauma (20.5%,4.5%; P=0.000), transverses-sigmoid sinus asymmetry (83.6%,65.7%; P=0.001).And the risk factor for DAVF are as following:female (OR2.605,95%C.I.1.467±4.626, P=0.001), age (OR1.039,95%C.I.1.021-1.057, P=0.000), sinus thrombosis (OR17.289,95%C.I.3.633-82.272, P=0.000), head trauma(OR13.618,95%C.I.4.841-38.307, P=0.000), and transverses-sigmoid sinus asymmetry (OR3.069,95%C.I.1.599-5.892, P=0.001)ConclusionPatients with elder age, female, sinus thrombosis, head trauma or transverses-sigmoid sinus asymmetry are more easy to catch a DAVF disease. The Second ChapterAngioarchitecture Characteristic and the Risk Factors of Aggressive DAVFBackgroundAggressive DAVF (aDAVF) may develop into venous cerebral infarction or fatal intracranial hemorrhage, there maybe relation with angioarchitecture (drainage mode, location, blood-supply type,) and the relation of the type of transverse sinus and the side of DAVF, but literature about DAVF’s angioarchitecture characteristic is limited and the reason of aDAVF is considered mainly as the result of cortex vein reflux at present, but ignoring other factors. So this chapter mainly focuses on the angioarchitecture characteristic as well as systems analysis of the risk factors for the aDAVF.ObjectiveTo study the angioarchitecture characteristic and analyze the risk factor of aDAVFMethods146cases with DAVF from Southern Medical University Zhujiang Hospital in the near10years were reviewed, including male56cases, female90cases, and age range from14to76years. Patients were divided into aDAVF group and bDAVF (benign DAVF) group, and the differences between the two groups were analyzed, including demographic characteristics, angiogram angioarchitecture characteristic (drainage mode, location, and type of blood supply) and transverse sinus type-DAVF side (transverse sinus symmetry, DAVF at the same side of the main transverse sinus and DAVF at the same side of the non-main transverse sinus), then the logistic regression analysis was used to analyze the above factors which having significant difference for the risk factors of aDAVF.ResultsThe significant differences between the bDAVF of control group and the aDAVF of patient group were respectively as follows:age (40.3±16.5岁,46.7±12.9%岁; P=0.021), transverse sinus type-DAVF side[transverse sinus symmetry28(28.6%),28(58.3%); DAVF at the same side of the main transverse sinus20(20.4%),12(25.0%); and DAVF at the same side of the non-main transverse sinus50(51.0%),8(16.7%); P=0.000], DAVF location [cavernous sinus78(79.6%),14(29.2%); large sinus8(8.2%),22(45.8%); non-sinus12(12.2%),12(25.0%); P=0.000],blood-supply system [single blood-supply system36(36.7%),8(16.7%); multi-blood-supply system62(63.3%),40(83.3%) P=0.013], Cognard type[I12(12.2%),6(12.5%), IIa48(49.0%),10(20.8%), Ⅱb16(16.3%),2(4.2%); Ⅱa+Ⅱb18(18.4%),26(54.2%); Ⅲ2(2.0%),2(4.2%); Ⅳ2(2.0%),2(4.2%); P=0.000].The risk factors for aDAVF were as follows:age (OR1.094,95%C.I.1.039-1.153, P=0.001), large sinus region (transver-sigmoid and superior sagittal sinus)(OR25.369,95%C.I.3.463-185.840, P=0.001), multi-blood-supply system (OR8.830,95%C.I.1.961-39.757, P=0.005), Cognardlla+b (OR13.756,95%C.I.1.934-97.868, P=0.009); and the protection factor of aDAVF was DAVF at the same side of the non-main transverse sinus (OR.108,95%C.I..022-531, P=0.006).ConclusionThe age of aDAVF group is high than bDAVF group; Compared with bDAVF, the angioarchitecture characteristics are as follows:Transverse sinus symmetry is the main type in aDAVF group, vs. DAVF at the same side of the non-main transverse sinus is the main type of bDAVF; aDAVF is more prone to involved in large sinus region, vs bDAVF mainly involved in cavernous sinus; The multi-blood-supply system is the main types of blood supply for aDAVF, vs the single-blood-supply system is the main types of blood supply for bDAVF; The main drainage system is Cognard Ⅱa+Ⅱb in aDAVF vs Cognard Ⅱ a in bDAVF.DAVFs with the following factor may easy develop into aDAVF, including edler age, locating in the big sinus area (transver-sigmoid and superior sagittal sinus) and non-sinus, multi-blood-supply system, and CognardⅡa+b type; but DAVF at the same side of the non-main transverse sinus may not prone to develop into aDAVF.The Third Chapter Endovascular Treatment of Dural Arteriovenous FistulaBackgroundIntervention embolization for DAVF has been the main treatment, and transvenous approach has been the primary treatment pathway, but it will lead to the corresponding sinus being sacrificed through such an approach. Though NBCA, which has be as a liquid embolic agents, could be used for DAVF embolization through the trans-arterious approach, but the application and curative effect were confined by its adhesion shortcomings. Recent, Onyx has emerged as a kind of non-adhesion of liquid embolic agents, which has been widely used in the brain arteriovenous malformation, and has been tried to be used for DAVF embolization. But the treatment approach and curative effect of using Onyx in different location of DAVF (cavernous sinus area, non-cavernous sinus area-big sinus area and the non-sinus area), are still lack of details.ObjectiveTo study the embolization approach for different location of DAVF (the cavernous sinus area, big sinus area and the non-sinus area) by using Onyx embolization, as well as evaluate its curative effect and advantage comparing with using NBCA embolization.Methodscases with DAVF were selected from department of neurosurgery, southern medical university zhujiang hospital in the near10years, for which NBCA or Onyx embolization was performed, including male42cases, female37cases, and a total of79cases, age range from13to64years old, and a mean of34.3+15.7years old. The hospitalization record, endovascular treatment records, and angiography imaging were retrospectively analyzed to find the differences in treatment approach and curative effect between Onyx and NBCA embolization.ResultsImmediate angiography showed that the total occlusion rate in NBCA and Onyx group was23.8%and75.7%, near-total occlusion rate was21.4%and24.3%occlusion, uncompleted occlusion rate is54.8%and0%, P=.000, respectively; Clinical and radiographic follow-up were performed in3-36months (mean11.1±7.8months), clinical follow-up in NBCA group and Onyx group showed that the cure rate was36.6%and76.9%, improvement rate was17.1%and7.7%, invalid or recurrence rate was46.3%and15.4%, respectively, P=.005; Angiography follow-up showed that the total occlusion rate in NBCA and Onyx group was30.0%and70.0%, near-total occlusion rate was16.7%and10.0%, uncompleted occlusion rate is53.3%and20.0%, respectively, P=.019; Respectively, complication rate in the two groups was9.5%and40.5%, P=.005; Transvenous approach in the two groups was9.5%and40.5%, transarterial way was85.7%and59.5%, transvenous+transarterial way was4.8%and0%, P=003; in addition, transvenous approach was successfully applied in all csDAVF by using Onyx embolization (including via inferior petrosal sinus13/15cases, superior ophthalmic vein2/15cases), while transarterial way was performed in all ncsDAVF (including via the meningeal artery in9/22cases, pillow artery2/22cases, ear hind artery8/22cases, and multi-artery3/22cases).ConclusionFor treating DAVF, curative effect of Onyx is better than that of NBCA, but need to pay attention to prevent and control the complications. When using Onyx, for csDAVF, transvenous way is the main embolization approach and the trans-inferior petrosal sinus is being used mostly, but for ncsDAVF, transarterial approach is the main treatment approach, and the trans-meninges artery and the posterior auricular artery are used mostly.