彩色多普勒超声在硬脑膜动静脉瘘及头皮动静脉畸形诊断中的应用
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摘要
目的 1 硬脑膜动静脉瘘(DAVF)是一种少见的颅内血管畸形，仅占颅内血管畸形的10％至15％。主要诊断依赖全脑血管造影和颈外动脉造影检查，应用CDFI诊断成人DAVF的研究未见报道。本实验应用CDFI评价DAVF患者的瘘口部位、颅内外供血动脉、颅内引流静脉、颈部血管的血流动力学改变，探讨其在诊断DAVF中的应用价值。
2 头皮动静脉畸形属于头皮血管畸形，是一种少见的位于头皮皮下组织内的动静脉直接交通的血管性疾病，确诊依赖脑血管造影。目前超声仅有从血管瘤的角度对该病的描述，而没有从血管畸形的角度来进行综合分析的研究。我们利用高频超声从病变血管团、供血动脉和引流静脉的角度综合分析头皮动静脉畸形的超声表现及血流动力学特点，评价超声对头皮动静脉畸形的诊断价值。
3 颅内血管病变可引起颅外血管的血流动力学改变。本实验通过分析A型颈动脉海绵窦瘘、脑AVM、脑动脉瘤等脑血管疾病颅外血管血流动力学参数的变化，评价不同脑血管病的颅外血管超声血流参数的变化特点，并为不同脑血管病的超声鉴别诊断提供依据。
第叨军医大学硕士学位论次
材料和方法病例组包括:13例DAvF患者、n例头皮动静脉畸形患
者、35例其他脑血管病患者(A型颈动脉海绵窦矮10例、脑动脉瘤12例、
脑AVM13例)。其中，依据主要供血动脉的来源不同将脑AVM分为2组，I
组主要供血动脉来源于椎一基底动脉系统7例，n组主要供血动脉来源于颈
内动脉系统6例。对照组选用60例健康志愿者。
检测方法:①应用CDFI通过颗窗、枕窗观察DAVF患者痰口部位，测量
其范围、血流频谱，检测供血动脉、引流静脉及颅外动脉血流参数的变化。
②使用高频探头探测头皮动静脉畸形病变部位，检测STA、OccA血流参数的
变化。③检测不同脑血管病的颅外血管血流动力学参数。
使用美国Acuson公司Sequoia 512型彩色超声诊断仪，测量的血流动
力学参数包括:内径、收缩期峰值流速(vmax)、舒张末流速(vmin)、平均
流速(Vmean)、阻力指数(Rl)。检测的颅外血管包括:ICA、ECA、VA、oeeA
和STA。所有病例均经全脑血管造影确诊，超声检测结果与全脑血管造影结
果及60例健康志愿者颅外动脉血流参数进行对比分析。
结果1 DAvF的cDFI表现:①DAvF痰口部位表现为异常不规则团状血
流影，内呈多方向、高速低阻的湍流频谱。音频信号为粗糙响亮的机器房样
音调。屡口部位血流参数为vmaX(1 05.6士32.9)cm/S，Vmin(72.0士22.9)
em/S，Vmean(87.0士26.0)cm/S，Rl(0.31士0.04);②13例DAVF疹口部
位的检出率为69%( 9/13)，横窦一乙状窦区71.4%(5/7)，海绵窦区100%(3/3);
③供血动脉检出42支(72.4%)，经横窦及眼上静脉的引流均检出，经上矢
状窦及皮层静脉的引流均未能检出;④E以的Vmin、vmean增快，R1降低(尸
<0.05);OeeA、STA的Vmax、Vmin、Vmean增快，Rl降低“丫0.05);ICA、
VA的各项血流参数与正常对照组相比，差异不具有显著性意义(只>0.05)。
2头皮动静脉畸形的超声表现:①病变区域表现为头皮下形态不规则的
低回声或无回声区，内呈网格状或蜂窝样无回声;无回声区内血流异常丰富，
第四军医大李硕士学位论文
充满闪烁明亮的五彩镶嵌状血流信号;②病变内部多普勒频谱表现为高速低
阻的动脉样血流频谱，Vmax(79.7士15.3)Cm/S，Vmin(44.9士6.7)em/s，
Vmean(68·9士12·1)em/s，Rl(0.41士0.09);③检出供血动脉20支，频
谱形态为高速低阻型，与正常对照组相比，内径、Vmax、Vmin及Vmean显著
增大，RI明显降低(产<0.05);④引流静脉血流速度加快，呈现脉动样低阻
力型频谱形态。
3不同脑血管病的颅外血管血流动力学参数的变化:①A型颈动脉海绵
窦凄患侧ICA的Vmin、Vmean增快，Rl降低(尸<0.05);②I组位于后颅窝
的7例中一特大型AVM，供血侧VA的Vmax、Vmin、Vmean增快，Rl降低(P
<0.05);11组位于顶、颗、额叶等部位的6例中一大型AVM，供血侧工以的
血流参数差异不具有显著性意义(只>0.05);③脑动脉瘤载瘤侧ICA的血流
参数差异不具有显著性意义“七>0.05);④A型颈动脉海绵窦痰、脑AVM、
脑动脉瘤的OccA及STA的血流参数差异不具有显著性意义“)0.05)。
结论1 cDFI可较好地显示横窦一乙状窦区及海绵窦区DAvF的屡口部
位，检出大部分颅内、颅外的供血动脉和引流静脉;通过对病变部位和颅外
血管血流动力学改变的分析，CDFI可提示DAVF的诊断，并能提供血流动力
学方面的量化指标。
2头皮动静脉畸形的超声表现符合其病理改变以及其高速低阻的高血流
病变的血流动力学特点，具有特征性，易与缓流病变头皮海绵状血管瘤的超
声图像相鉴别;应用高频超声检查病变，不仅能准确判断病变的范围、深度、
累及的重要组织，还能检出大部分供血动脉、引流静脉，从而做出头皮动静
脉畸形的定性诊断。
3位于后颅窝中型以上的脑AVM和A型颈动脉海绵窦痰的供血动脉颅外
段血管超声血流参数的变化具有特征性，而位于顶、颗、额叶等部位的中-
大型脑AVM和脑动脉瘤的供血或载瘤动脉颅外段血管超声血流参数的变化不
第四军医大学硕士学位论义
具有特征性，可为临床诊断脑血管病提供参考，并为不同脑血管病的
Objective 1 The dural arteriovenous fistulas (DAVF) is a rare intracranial vascular malformation accounting for only 10%~15% of all intracranial vascular malformations. The gold standard for the detection and characterization of these diseases is cerebral angiography and external carotid artery angiography. To our knowledge, we have not found any descriptions about preliminary diagnosis of DAVF based on the CDFI findings alone in adults. The purpose of this work was to characterize the hemodynamic changes of arteriovenous fistulas, feeding arteries, draining veins and extracranial arteries in patients with DAVF and to evaluate the diagnostic value of CDFI in DAVF.
2 Scalp arteriovenous malformation is a rare extracranial vascular malformation with abnormal arteriovenous communication lying within the subcutaneous of the scalp. The diagnosis of the lesion based on cerebral angiography. Review of the literature we have just found the ultrasonic descriptions about the lesions from the point of hemangioma. The systematical investigations of the lesions from the point of arteriovenous malformations have not been found. We analyzed the ultrasonic
manifestations and the hemodynamic changes systematically in patients with scalp arteriovenous malformations from the point of arteriovenous malformations by high frequency ultrasound and evaluated the diagnostic value of ultrasound in scalp arteriovenous malformations.
3 The intracranial vascular diseases cause the hemodynamic changes of extracranial vessels. We analyzed and characterized the hemodynamic changes of extracranial vessels in patients with direct carotid-cavernous fistulae (type A), cerebral arteriovenous malformations (AVM) and cerebral aneurysm so as to provide gist of ultrasonic differentiation in cerebral vascular diseases.
Methods Thirteen patients with DAVF, 11 cases with scalp arteriovenous malformation and 35 cases with other intracranial vascular diseases (10 cases of direct carotid-cavernous fistulae, 12 cases of cerebral aneurysm and 13 cases of cerebral AVM) were studied through CDFI. Cerebral AVM were divided into two groups based on the origination of feeding artery: I group composed of 7 cases, feeding arteries originated from vertebrobasilar artery, II group composed of 6 cases, feeding arteries originated from internal carotid artery. The normal contrast group was consisted of 60 healthy volunteers.
Detecting technique:(1)Patients with DAVF were studied by CDFI through the temporal and occipital window. The arteriovenous fistulas and spectra in it were detected. Hemodynamic parameters were measured in the feeding arteries, draining veins and extracranial arteries. (2)The head soft tissue mass, bilateral superficial temporal artery and occipital artery in patients with scalp arteriovenous malformation were examined using high frequency ultrasound. (3) Hemodynamic parameters within extracranial vessels were measured in patients with different intracranial vascular diseases.
We used Acuson Sequoia 512 computed sonographer. The diameter, Vmax, Vmin, Vmean and Rl of the abnormal vessels were recorded. The extracranial vasculars such as ICA, ECA, VA, OccA and STA were checked. All of the cases were confirmed by the cerebral angiography. The ultrasonic findings were compared and analyzed with those of the cerebral angiography and those by ultrasonography in 60 healthy volunteers.
Results 1 The CDFI manifestations of DAVF: (1)The fistulas of DAVF presented heterogenous mosaic flashes. The spectral shape in it was of multiple directions, high velocity and low resistance with Vmax (105.6 + 32.9) cm/s, Vmin (72.0 + 22.9) cm/s, Vmean (87.0 + 26.0) cm/s, Rl (0.31 + 0.04) . The acoustic frequency signals were rough and alound. (2) Identification rate of the fistulas were 69% (9/13) in 13 cases with DAVF by CDFI. Identification rate were 71.4% (5/7) for the DAVF of transverse-sigmoid sinus and 100% (3/3) for the DAVF of cavernous sinus. (3)Feeding arteries detected by CDFI counted up to 42 (72.4%). The venous drainage through transverse sin
2 头皮动静脉畸形属于头皮血管畸形，是一种少见的位于头皮皮下组织内的动静脉直接交通的血管性疾病，确诊依赖脑血管造影。目前超声仅有从血管瘤的角度对该病的描述，而没有从血管畸形的角度来进行综合分析的研究。我们利用高频超声从病变血管团、供血动脉和引流静脉的角度综合分析头皮动静脉畸形的超声表现及血流动力学特点，评价超声对头皮动静脉畸形的诊断价值。
3 颅内血管病变可引起颅外血管的血流动力学改变。本实验通过分析A型颈动脉海绵窦瘘、脑AVM、脑动脉瘤等脑血管疾病颅外血管血流动力学参数的变化，评价不同脑血管病的颅外血管超声血流参数的变化特点，并为不同脑血管病的超声鉴别诊断提供依据。
第叨军医大学硕士学位论次
材料和方法病例组包括:13例DAvF患者、n例头皮动静脉畸形患
者、35例其他脑血管病患者(A型颈动脉海绵窦矮10例、脑动脉瘤12例、
脑AVM13例)。其中，依据主要供血动脉的来源不同将脑AVM分为2组，I
组主要供血动脉来源于椎一基底动脉系统7例，n组主要供血动脉来源于颈
内动脉系统6例。对照组选用60例健康志愿者。
检测方法:①应用CDFI通过颗窗、枕窗观察DAVF患者痰口部位，测量
其范围、血流频谱，检测供血动脉、引流静脉及颅外动脉血流参数的变化。
②使用高频探头探测头皮动静脉畸形病变部位，检测STA、OccA血流参数的
变化。③检测不同脑血管病的颅外血管血流动力学参数。
使用美国Acuson公司Sequoia 512型彩色超声诊断仪，测量的血流动
力学参数包括:内径、收缩期峰值流速(vmax)、舒张末流速(vmin)、平均
流速(Vmean)、阻力指数(Rl)。检测的颅外血管包括:ICA、ECA、VA、oeeA
和STA。所有病例均经全脑血管造影确诊，超声检测结果与全脑血管造影结
果及60例健康志愿者颅外动脉血流参数进行对比分析。
结果1 DAvF的cDFI表现:①DAvF痰口部位表现为异常不规则团状血
流影，内呈多方向、高速低阻的湍流频谱。音频信号为粗糙响亮的机器房样
音调。屡口部位血流参数为vmaX(1 05.6士32.9)cm/S，Vmin(72.0士22.9)
em/S，Vmean(87.0士26.0)cm/S，Rl(0.31士0.04);②13例DAVF疹口部
位的检出率为69%( 9/13)，横窦一乙状窦区71.4%(5/7)，海绵窦区100%(3/3);
③供血动脉检出42支(72.4%)，经横窦及眼上静脉的引流均检出，经上矢
状窦及皮层静脉的引流均未能检出;④E以的Vmin、vmean增快，R1降低(尸
<0.05);OeeA、STA的Vmax、Vmin、Vmean增快，Rl降低“丫0.05);ICA、
VA的各项血流参数与正常对照组相比，差异不具有显著性意义(只>0.05)。
2头皮动静脉畸形的超声表现:①病变区域表现为头皮下形态不规则的
低回声或无回声区，内呈网格状或蜂窝样无回声;无回声区内血流异常丰富，
第四军医大李硕士学位论文
充满闪烁明亮的五彩镶嵌状血流信号;②病变内部多普勒频谱表现为高速低
阻的动脉样血流频谱，Vmax(79.7士15.3)Cm/S，Vmin(44.9士6.7)em/s，
Vmean(68·9士12·1)em/s，Rl(0.41士0.09);③检出供血动脉20支，频
谱形态为高速低阻型，与正常对照组相比，内径、Vmax、Vmin及Vmean显著
增大，RI明显降低(产<0.05);④引流静脉血流速度加快，呈现脉动样低阻
力型频谱形态。
3不同脑血管病的颅外血管血流动力学参数的变化:①A型颈动脉海绵
窦凄患侧ICA的Vmin、Vmean增快，Rl降低(尸<0.05);②I组位于后颅窝
的7例中一特大型AVM，供血侧VA的Vmax、Vmin、Vmean增快，Rl降低(P
<0.05);11组位于顶、颗、额叶等部位的6例中一大型AVM，供血侧工以的
血流参数差异不具有显著性意义(只>0.05);③脑动脉瘤载瘤侧ICA的血流
参数差异不具有显著性意义“七>0.05);④A型颈动脉海绵窦痰、脑AVM、
脑动脉瘤的OccA及STA的血流参数差异不具有显著性意义“)0.05)。
结论1 cDFI可较好地显示横窦一乙状窦区及海绵窦区DAvF的屡口部
位，检出大部分颅内、颅外的供血动脉和引流静脉;通过对病变部位和颅外
血管血流动力学改变的分析，CDFI可提示DAVF的诊断，并能提供血流动力
学方面的量化指标。
2头皮动静脉畸形的超声表现符合其病理改变以及其高速低阻的高血流
病变的血流动力学特点，具有特征性，易与缓流病变头皮海绵状血管瘤的超
声图像相鉴别;应用高频超声检查病变，不仅能准确判断病变的范围、深度、
累及的重要组织，还能检出大部分供血动脉、引流静脉，从而做出头皮动静
脉畸形的定性诊断。
3位于后颅窝中型以上的脑AVM和A型颈动脉海绵窦痰的供血动脉颅外
段血管超声血流参数的变化具有特征性，而位于顶、颗、额叶等部位的中-
大型脑AVM和脑动脉瘤的供血或载瘤动脉颅外段血管超声血流参数的变化不
第四军医大学硕士学位论义
具有特征性，可为临床诊断脑血管病提供参考，并为不同脑血管病的
Objective 1 The dural arteriovenous fistulas (DAVF) is a rare intracranial vascular malformation accounting for only 10%~15% of all intracranial vascular malformations. The gold standard for the detection and characterization of these diseases is cerebral angiography and external carotid artery angiography. To our knowledge, we have not found any descriptions about preliminary diagnosis of DAVF based on the CDFI findings alone in adults. The purpose of this work was to characterize the hemodynamic changes of arteriovenous fistulas, feeding arteries, draining veins and extracranial arteries in patients with DAVF and to evaluate the diagnostic value of CDFI in DAVF.
2 Scalp arteriovenous malformation is a rare extracranial vascular malformation with abnormal arteriovenous communication lying within the subcutaneous of the scalp. The diagnosis of the lesion based on cerebral angiography. Review of the literature we have just found the ultrasonic descriptions about the lesions from the point of hemangioma. The systematical investigations of the lesions from the point of arteriovenous malformations have not been found. We analyzed the ultrasonic
manifestations and the hemodynamic changes systematically in patients with scalp arteriovenous malformations from the point of arteriovenous malformations by high frequency ultrasound and evaluated the diagnostic value of ultrasound in scalp arteriovenous malformations.
3 The intracranial vascular diseases cause the hemodynamic changes of extracranial vessels. We analyzed and characterized the hemodynamic changes of extracranial vessels in patients with direct carotid-cavernous fistulae (type A), cerebral arteriovenous malformations (AVM) and cerebral aneurysm so as to provide gist of ultrasonic differentiation in cerebral vascular diseases.
Methods Thirteen patients with DAVF, 11 cases with scalp arteriovenous malformation and 35 cases with other intracranial vascular diseases (10 cases of direct carotid-cavernous fistulae, 12 cases of cerebral aneurysm and 13 cases of cerebral AVM) were studied through CDFI. Cerebral AVM were divided into two groups based on the origination of feeding artery: I group composed of 7 cases, feeding arteries originated from vertebrobasilar artery, II group composed of 6 cases, feeding arteries originated from internal carotid artery. The normal contrast group was consisted of 60 healthy volunteers.
Detecting technique:(1)Patients with DAVF were studied by CDFI through the temporal and occipital window. The arteriovenous fistulas and spectra in it were detected. Hemodynamic parameters were measured in the feeding arteries, draining veins and extracranial arteries. (2)The head soft tissue mass, bilateral superficial temporal artery and occipital artery in patients with scalp arteriovenous malformation were examined using high frequency ultrasound. (3) Hemodynamic parameters within extracranial vessels were measured in patients with different intracranial vascular diseases.
We used Acuson Sequoia 512 computed sonographer. The diameter, Vmax, Vmin, Vmean and Rl of the abnormal vessels were recorded. The extracranial vasculars such as ICA, ECA, VA, OccA and STA were checked. All of the cases were confirmed by the cerebral angiography. The ultrasonic findings were compared and analyzed with those of the cerebral angiography and those by ultrasonography in 60 healthy volunteers.
Results 1 The CDFI manifestations of DAVF: (1)The fistulas of DAVF presented heterogenous mosaic flashes. The spectral shape in it was of multiple directions, high velocity and low resistance with Vmax (105.6 + 32.9) cm/s, Vmin (72.0 + 22.9) cm/s, Vmean (87.0 + 26.0) cm/s, Rl (0.31 + 0.04) . The acoustic frequency signals were rough and alound. (2) Identification rate of the fistulas were 69% (9/13) in 13 cases with DAVF by CDFI. Identification rate were 71.4% (5/7) for the DAVF of transverse-sigmoid sinus and 100% (3/3) for the DAVF of cavernous sinus. (3)Feeding arteries detected by CDFI counted up to 42 (72.4%). The venous drainage through transverse sin
引文
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