探讨枕骨大孔区硬脑膜动静脉瘘（DAVF）的临床特点、诊断及外科治疗策略。

回顾性分析南京大学医学院附属鼓楼医院2015年1月1日至2020年12月31日收治的12例枕骨大孔区DAVF患者，男性10例，女性2例，年龄27~61岁（平均43.1岁）。11例以蛛网膜下腔出血起病，1例因枕部巨大皮下血肿及杂音就诊。所有患者均行CT血管造影检查，仅3例发现枕骨大孔区异常血管影，最终确诊依赖数字减影血管造影，病变位于右侧9例，左侧3例。9例为单纯椎动脉脑膜后支供血，2例为多支脑膜动脉供血，分别来自椎动脉、咽升动脉和枕动脉，1例为椎动脉直接供血伴颈外动脉和枕动脉供血。均采用改良的枕下极外侧入路切除病变。分析DAVF患者手术及术后情况。

11例患者直接行瘘口电凝烧灼及粗大的回流静脉切除，1例复杂DAVF行复合手术，借助于血管内球囊封堵技术，切除畸形血管。术后出院前常规造影复查示瘘口完全消失，无异常回流静脉显影。11例术后恢复良好，1例重度残疾。

枕下远外侧入路可充分显露枕骨大孔区DAVF及畸形血管，电凝切断瘘口及畸形团简单易行，效果好，但要注意保护脑干周围的穿支血管，防止脑干缺血。

To explore the clinical features, diagnosis and surgical strategy of the dural arteriovenous fistula (DAVF) at the foramen magnum.

12 cases of occipital large pore area DAVF admitted to Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from January 1, 2015 to December 31, 2020, among whom there were 10 males and two females aged from 27 to 61 years, were retrospectively analyzed. The cranial computerized tomography scans of all patients showed subarachnoid hemorrhage in 11 patients, abnormal vessels in the craniocervical region revealed by CTA in three patients. Pre-operative digital subtraction cerebral angiography showed a DAVF at the foramen magnum. The lesion located in the right side in 9 cases and left side in three cases. Nine DAVFs were fed by the meningeal artery from vertebral artery, whilst the others were fed by dural branches of the vertebral artery, occipital artery and/or the ascending pharyngeal artery. The far lateral suboccipital approach was performed with hemilaminectomy of C1 and C2. Surgical and postoperative conditions of patients with DAVF were analyzed.

11 patients underwent direct microsurgical electrocoagulation and disconnection of the arteriovenous shunt. One patient underwent resection of fistula and tortuous enlarged varix through the help of endovascular balloon control for the vertebral artery in the hybrid room via an enlargement of the foramen magnum and a hemilaminectomy at C1 by the far lateral suboccipital approach. Post-operative angiography confirmed complete obliteration of the fistula. All patients were uneventful except one patient with serious disability due to brainstem injury.

The far lateral suboccipital approach is suitable for operative exposure of a DAVF at the foramen magnum. It can be treated effectively and with minimal surgical trauma by microsurgical electrocoagulation and disconnection of the shunt. Attention should be taken for prevention of injury to normal vital vessels to the brainstem.