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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3644_Библиотеки_им_академика_М_И_Перельмана
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7Dural Arteriovenous Shunts422
Scheme 7.3. Effect of cavernous capture
Ta ble 7.3. Analysis of pial, straight sinus,or SSS reflux (Barbosa et al. 2003)
Reflux No reflux
Favorable progression 6 (40.0%) 11 (73.3%)
Unfavorable progression 8 (53.3%) 4 (26.7%)
No follow-up 1 (6.7%) 0
To tal no.of patients 15 (50.0%) 15 (50.0%)
423Fetal and Postnatal Changes of Sinuses
Scheme 7.4. Effect of jugular bulb dysmaturation
Ta ble 7.4. Analysis of jugular bulb dysmaturation
Jugular bulb No jugular bulb
dysmaturation dysmaturation
Favorable progression 6 (37.5%) 11 (78.6%)
Unfavorable progression 9 (56.3%) 3 (21.4%)
No follow-up 1 (6.25%) 0
To tal no.of patients 16 (53.3%) 14 (46.7%)
occluded,then the sinuses will likely also thrombose,resulting in the absence of outlets for the brain leading to poor outcome.The posterior fossa drainage and deep cerebral structures must be carefully analyzed. Associated deep DVAs are not rare,adding further to the clinical eloquence
when involved by the reflux and to the extent of the infarction if thrombosis is to occur.
The endovascular interventions include embolization of high-flow
AVFs with glue (Figs. 7.20, 7.21), exclusion of converging DAVS into venous spaces by transvenous deposition of coils and separation of the
DSM venous drainage from the normal brain drainage with coils
(Fig. 7.22). Most techniques were combined, staged, and highly targeted.
There has been no attempt to perform a surgical dural sinus bypass in
our experience. Stenting of a highly symptomatic narrowed jugular bulb
following thrombosis of the contralateral transverse sinus resulted in
excellent immediate result but secondarily,stent stenosis and thromboses
occurred,which was eventually resistant to several repeated angioplasties
and anticoagulation therapy (Vilela et al.2001).
7Dural Arteriovenous Shunts424
Scheme 7.5. Effect of pial vein reflux with thrombosis
425Fetal and Postnatal Changes of Sinuses
Scheme 7.6. Effect of pial vein reflux without thrombosis
Ta ble 7.5. Analysis of cavernous capture
To tal cavernous Partial cavernous No cavernous
capture capture capture
Favorable progression 10 (71.4%) 5 (62.5%) 2 (25.0%)
Unfavorable progression 3 (21.4%) 3 (37.5%) 6 (75.0%)
Lost to follow-up 1 (7.1%) 0 0
To tal no.of patients 14 (46.7%) 8 (26.7%) 8 (26.7%)
7Dural Arteriovenous Shunts426
Fig. 7.20A–I. A 6-month-old boy presented a torcular DSM (A) with a significant
single AVF along the falx cerebelli (B, C). Selective embolization and glue deposition
(D, E) allowed the previously dilated torcular (F) to shrink and remodel (G). Angiography confirms the quality of the venous remodeling (H, I).E–I see p.427
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427Fetal and Postnatal Changes of Sinuses
Fig. 7.20A–I. Legend see p. 426
7Dural Arteriovenous Shunts428
Fig. 7.21A–F. Legend see p. 429
In Barbosa’s series (Barbosa et al. 2003), the clinical progression of
14 (52%) conservatively treated patients was good in five out of
14 cases (35.7%) where favorable outcome was anticipated without
treatment (four patients with spontaneous thrombosis) (Figs. 7.23,
7.24; Table 7.6). The progression was poor in nine of 14 cases (64.3%)
where no acceptable therapeutic goal could be set and all patients
died. Sixteen (53.3%) patients were embolized, 12 of 16 (75%) with
glue via the transarterial approach; four of 16 (25%) were treated with
glue and coils via the transarterial and transvenous approaches in the
same or separate sessions.There was no morbidity or mortality related to the procedures themselves.Excluding the one patient lost to follow-up, the post-therapeutic follow-up period ranged from 3 to
84 months, with a mean follow-up of 3.6 years. The clinical progression of 16 embolized patients was good in 12 of 16 (75.0%) with eight
of 12 (66.7%) cured, and was poor in three of 16 (18.8%) cases, as all
patients died despite embolization.
The analyses of the final clinical results are shown in Table 7.7.The initial
score had been good (score, 3–5) in only 12 (50.0%). Good outcome
scores were noted in 17 of 19 (89.5%) of the surviving children.Favorable
clinical progression with morphologic exclusion was noted in 10 of 17
(58.8%) and conversely 11 of 12 (90.0%) with unfavorable progression
died.
429Fetal and Postnatal Changes of Sinuses
Fig. 7.21A–H. A 6-month-old boy with lateralized DSM along the embryonic tentorial sinus (A–D). The lesion is partially thrombosed yet embolization with glue was
performed in two sessions. Eight months later, the lesion was completely excluded
and the remodeling completed (E–H)
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7Dural Arteriovenous Shunts430
Fig. 7.22A–F. Legend see p. 431
431Fetal and Postnatal Changes of Sinuses
Fig. 7.22A–H. A 1-year-old girl presenting with DSM with reflux into the straight sinus in relation to a bilateral dysmaturation of the jugular bulbs. Although the lesion
is located at the torcular (A),the presence of a bilateral cavernous capture allowed for
separation of the DSM circulation and that of the normal brain (B, C) prior to embolization. Five years later, the brain was draining normally (D, E); a posterior fossa
DVA (F, G ) drained into the superior petrosal sinus on the left. The lesion was nearly
completely excluded but no longer presented a risk (H). Nine years after the venous
separation, the child was normal
Ta ble 7.6. Clinical progression of patients
Embolized Not embolized
Favorable progression 12 (75.0%) 5 (35.7%)
Unfavorable progression 3 (18.8%) 9 (64.3%)
Lost to follow-up 1 (6.3%) 0
To tal no.of patients 16 (53.3%) 14 (46.7%)
Ta ble 7.7. Overall results
Clinical situation No.of patients
Favorable clinical progression 17/29 (58.6%)
Favorable clinical progression with morphological exclusion 10/17 (58.8%)
Unfavorable clinical progression 12/29 (41.4%)
Unfavorable clinical progression with death 11/12 (90.9%)
No follow-up 1/30 (3.3%)
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