| Chapter1Prognostic Factors of Dural Arteriovenous FistulaBackgroud DAVF is an abnormal connection between arteries and cortical venous or dural sinus. It’s clinical traits varies. DAVFs in different locations with different signs and symptoms, radiological characters, artery feeders and treatment methods have different prognosis. Most DAVFs are benign. However, DAVFs with intracranial hemorrhage lead to poor outcome. A model of predicting the prognosis of DAVF is needed. The relation-ship between the outcome of DAVF and its characters of symptoms and radiology is still unclear.Aim Collect the data of DAVF and investigate the relationship between the data and out-come of DAVFMethods79cases collected from2010to2015in Zhejiang University Second Affiliated Hospital, including52males,27females, average age was52.2years. Collect the clincial symptoms, location of DAVF, Cognard type, artery feeders, treatment methods, outcome and follow-up mRS scales from these cases. All cases were divided into two groups based on mRS scales. Kruskal-Wallis test and Logistic regression was done to analyze the prognostic factors of DAVF.Results In all cases,70were spontanoues (88.6%). In the clinical symptoms,41had headache (51.9%),32had cavernous symptoms (40.5%),13had intracranial hemorrhage and NHND (16.5%).31DAVFs were located near cavernous sinus (41.3%),18were lo-cated near tansverse and sigmoid sinus (24%),12were near tentorium or straight sinus (16%),9were on anterior cranial fossa (12%) and superior sagittal sinus (6.7%). In Cog-nard type,20DAVFs were low aggressive (25.3%), with4of Cognard Ⅰ,16of Cognard Ⅱa.60aggressive DAVF with19of Cognard Ⅱb (24.1%),10of Cognard Ⅱa+Ⅱb (12.7%),11of Cognard III (13.9%),19of Cognard IV (24.1%) and1of Cognard V (1.3%).53DAVFs accepted TAE (67.1%),13accepted open surgery (16.5%),12had TVE (15.2%),1with ra-diology treatment (1.3%). Total cure rate was55.7%, with100%in surgery DAVFs,41.5%in TAE and75%in TVE. On average follow-up time31.1months, average mRS scales was2.1±1.3, with good outcome (mRS<2) in43cases and poor outcome (mRS>2) in19cases.Kruskal-Wallis test show significant prognosis difference in different initial symp-toms. Intracranial hemorrhage patients had poor outcome than those with headache and tinnitus. In logistic multiple factors regression, no factors were found related to the prog-nosis except the follow-up symptomsConclusion1. Most cases were spontaneous DAVF。2. Headache was the most common symptoms, followed by cavernous symptoms. Most DAVFs were located near cavernous sinus and transverse and sigmoid sinus. DAVFs in female were mostly located near cavernous sinus. There was a significant differ-ence on DAVF location between male and female.3. Clinical symptoms, Cognard types, treatment methods were related to the DAVF lo-cations. Cavernous symptoms and tinnitus were mostly seen in cavernous sinus and transverse and sigmoid sinus DAVFs. DAVFs in cavernous sinus were mostly benign, while DAVFs in anterior cranial fossa and tentorium were aggressive. Open surgery were used in anterior cranial fossa DAVFs, TVE were mostly used in cavernous sinus DAVF and TAE was suitable for DAVFs in almost erery locations4. In single factor analysis, outcome of DAVF was related to initial clinical symptoms. Patients presented with intracranial hemorrhage had poor outcome. In logistic regres-sion, no factors were found related to the prognosis except the follow-up symptoms, which indicates the important of early treatment before ICH events. Chapter2Endovascular Treatment of Dural Arterivenous FistulaBackgroud Treatment of DAVF varies, including conservative observation, surgery, ra-diology and endovascualr treatment. Since endovascualr treatment could lead to the fistula directly, it is considered as the most ideal method to treat DAVF. TVE was considered as the most safe and effective method. TAE was considered as the sencond line therapy after TVE for its compliations and difficult processing. With the development of endovas-cualr technique and the Onyx embolization materials, the safety and effecay of TAE was improved.Aim Collect the data of TAE and TVE on DAVFs’locations, complete occlusion rate, complications and prognosis, to evaluate the methods of TAE and TVE.Methods This was a retrospectrum case control study.46cases were collected from2010to2015in Zhejiang University Second Affiliated Hospital, all accepted endovascular treat-ment and complete the follow-up. All cases were divided into TAE and TVE groups, to in-vestigate the locations of DAVFs, Cognard types, complete occlusion rate and mRS scales in different groups.Results In46cases,36accepted TAE,10accepted TVE. Complete occlusion rate was52.2%, with44.4%in TAE and80%in TVE (p=0.038). In TAE group,18were located near cavernous sinus,9were near transverse and sigmoid sinus,6were near straight sinus and tentorium,2were near superior sagittal sinus,1was on anterior cranial.fossa. Com-plete occlusion in those locations were38.9%,44.4%,50%,50%,0%respectively. In TVE groups,5were near cavernous sinus,3were near transverse and sigmoid sinus,2were near straight sinus and tentorium. No DAVFs near superior sagittal sinus or on anterior cranial fossa were treated by TVE.26DAVFs were occlued with Onyx,8with n-BCA,2with coils in TAE group. In TVE group,8were occlued with coils,1with Onyx and1with Onyx and coils at same time. Complete occlusion rate of n-BCA was50%. Complete occlusion rate of Onyx and coils were42.3%and50%in TAE. Complete occlusion rate of coils in TVE was77.8%. On follow-up, average mRS scales was2.03±1.21and0.80±1.06in TAE and TVE groups, without significant difference.1patient in TAE group had decreased acuity in right eye, another patient had occular nerve palsy.1patient in TVE group had incread headache. No other complications were found in both treatment groups.Conclusion1. In our DAVF cases, complete occlusion rate was higher in TVE than TAE.2. TAE was used for DAVFs in cavernous sinus, transverse and sigmoid sinus, straight sinus and tentorium, superior sagittal sinus and anterior cranial fossa. In our cases, no DAVF in superior sagittal sinus and anterior cranial fossa or above Cognard Ⅲ were treated by TVE.3. On follow-up, there is no difference between TAE and TVE. Both TAE and TVE were safe as a treatment of DAVF.4. Although TVE had higher complete occlusion rate than TAE, TAE was suitable for DAVFs in almost every locations with nearly outcome of TVE. Consider the cost efficiency rate, TAE was a proper treatment method of DAVF and was wroth to spread in developing countries like China. |
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