Onyx胶栓塞脑动静脉畸形31例

背景：在脑动静脉畸形的血管内栓塞治疗中,栓塞材料的选用在很大程度上决定血管内栓塞治疗的效果。Onyx胶是近年研制的一种新型液体栓塞剂,具有不粘管、弥散均匀及可控性好等优点。 目的：总结新型液态栓塞剂Onyx胶栓塞脑动静脉畸形31例的技术要点和临床疗效。 方法：应用Onyx胶栓塞脑动静脉畸形31例,均采用Seldinger技术在股动脉内置入6F动脉鞘,6F导引导管插入颈内动脉或椎动脉,Marathon微导管超选择进入畸形血管团内,采用“注胶-返流-停止-再注胶”技术长时间缓慢注射Onyx胶栓塞脑动静脉畸形。 结果与结论：栓塞后脑动静脉畸形闭塞40%~60% 8例,60%~90% 7例,90%以上(完全栓塞)16例。未能完全栓塞的15例中,4例接受手术治疗,其中3例痊愈,1例单侧肢体乏力,肌力Ⅳ级;6例患者术后辅以伽玛刀治疗,其中2例1年以后复查DSA显示脑动静脉畸形完全闭塞。提示Onyx可提高脑动静脉畸形的栓塞效果,但应正确采用栓塞技术和注意预防并发症。     

血管内介入治疗脑动静脉畸形

目的探讨血管内栓塞治疗脑动静脉畸形(AVM)的临床效果和安全性. 方法应用血管内栓塞治疗脑AVM 11例,栓塞剂为NBCA,栓塞后3例行手术切除,3例行γ-刀治疗.结果 1例完全栓塞,5例栓塞70%～90%,3例栓塞50%～70%,2例栓塞小于50%.生活、工作完全正常治愈5例,症状明显改善4例,症状无改善2例.结论血管内栓塞治疗脑AVM的方法是相对安全的,可治愈部分脑AVM,对于大型、重要功能区的脑AVM,血管内栓塞联合手术或放疗可提高治愈率,降低致残率和死亡率.     

血管内介入治疗脑动静脉畸形

目的 探讨血管内栓塞治疗脑动静脉畸形(AVM)的临床效果和安全性．方法 应用血管内栓塞治疗脑AVMll例，栓塞剂为NBCA，栓塞后3例行手术切除，3例行γ-刀治疗．结果 1例完全栓塞，5例栓塞70％—90％，3例栓塞50％—70％，2例栓塞小于50％．生活、工作完全正常治愈5例，症状明显改善4例，症状无改善2例．结论 血管内栓塞治疗脑AVM的方法是相对安全的，可治愈部分脑AVM，对于大型、重要功能区的脑AVM，血管内栓塞联合手术或放疗可提高治愈率，降低致残率和死亡率．     

15例脑动静脉畸形的手术治疗

目的讨论手术切除治疗脑动静脉畸形（AVM）。方法回顾性分析我院自2006年5月～2009年12月间显微手术治疗的15例脑AVM。结果本组术后无死亡病例。术后1天内出现残腔血肿1例,占本组的6.7%,3天内局部脑肿胀2例,占本组的13.3%,以上3例均经加强脱水降颅压、控制血压等治疗而好转。术后患者无再次癫痫发作病例。其余12例（占本组的80.0%）恢复良好,复查DSA均显示脑动静脉畸形已全切除。本组15例随访DSA3年,均无脑动静脉畸形复发病例。结论开颅手术切除是治疗大中型脑AVM的有效手段。在治疗时,应该积极防治正常灌注压突破出血及其他并发症,通过精细的显微手术操作以获得更好的治疗效果。     

脊髓髓内动静脉畸形血管构筑学分析及其对治疗的启示

目的　探讨脊髓髓内动静脉畸形(SAVM)的血管构筑从而选择适宜的治疗方式。材料和方法　回顾性分析本中心治疗的120例SAVM病人的临床资料、血管造影影像资料及治疗方法和效果。结果　根据脊髓髓内动静脉畸形团的形状,将AVM分成两种类型：团块型和幼稚型。血管构筑学分析包括供血动脉、供血方式、伴随病变。其供血动脉为脊髓前动脉、脊髓后动脉和/或软膜动脉。经超选择脊髓血管造影可见畸型团有5种构筑方式：(1)终末供血形式,本组104例行栓塞治疗,其中85例单纯栓塞,70例神经功能恢复与改善;19例行术前栓塞、减少术中出血;(2)穿支供血形式本组16例,少量部分的用颗粒栓塞,栓塞后症状均改善;(3)动静脉直接交通1例;(4)AVM伴有动脉瘤13例,首先行动脉瘤栓塞;(5)AVM含有静脉动脉瘤样扩张2例。结论　脊髓髓内AVM的血管构筑学有助于选择治疗方案,终末型供血可行胶栓塞。穿支供血只能少量部分的用颗粒栓塞。AVM内的动脉瘤应首先栓塞,可明显减少再出血的危险。团块型AVM术前栓塞有利于手术切除。幼稚型AVM只能栓塞治疗。     

脑动静脉畸形4例报告

目的探讨脑动静脉畸形（AVM）的临床特征、治疗方式的选择及操作技巧。方法回顾分析4例脑动静脉畸形患者的临床资料。结果右额脑动静脉畸形1例，左额脑动静脉畸形1例，右颞脑动静脉畸形1例，左颞脑动静脉畸形1例。其中1例为外伤后无意中发现，其余3例均以脑出血为首发表现。4例均经过手术治疗完全切除，均无任何后遗症。结论治疗AVM的基本目标是降低自发性出血的风险。对于已经出血的AVM可以积极手术治疗，对于无症状的巨大AVM，在条件允许的情况下手术切除仍是最根本的治疗方法。     

脑内动静脉畸形急性出血的治疗体会

近10年,本院收治了12例脑内动静脉畸形(AVM)急性出血的病人,就其治疗进行分析,现报告如下。 一、临床资料 男7例,女5例,年龄为26～65岁,平均41.5岁;自发性出血4例,表现为昏迷及去脑强直;出血继发于血管内栓塞治疗后8例,4例于栓塞时发生,余4例分别发生于栓塞后1、2、24及72 h,该8例出血时表现为突发性意识状态恶化,偏瘫或去脑强直。病人入院或病情突变后立即CT检查,均见AVM附近巨大血肿。自发出血4例中,2例增强CT扫描提示AVM,另2例发病前已经脑血管造影证实AVM,此4例术前未做脑血管造影。     

介入栓塞联合显微手术一站式切除高级别脑动静脉畸形疗效分析

目的探讨介入栓塞联合显微手术一站式切除高级别脑动静脉畸形的手术要点和临床价值。方法回顾性分析使用介入栓塞联合显微手术一站式切除的33例高级别脑动静脉畸形患者的临床资料,包括临床表现、影像学特征、治疗指征和结果,并用改良的Rankin量表(mRS)评估结果。结果 19例(57. 6%)患者存在出血,7例(21. 2%)存在癫痫发作,6例(18. 2%)存在头痛,1例(3. 0%)出现进行性神经功能缺损。根据Spetzler-Martin分级(SMG):Ⅲ级7例(21. 2%)、Ⅳ级22例(66. 7%)、Ⅴ级4例(12. 1%)。切除术后共7例(21. 2%)患者出现治疗相关并发症。32例(97. 0%)患者术后造影显示畸形团完全闭塞。无死亡患者。随访3～36个月,平均9. 6个月,31例(93. 9%)患者mRS为0分,1例(3. 05%)患者mRS为1分,1例(3. 05%)患者mRS为4分。结论介入栓塞联合显微手术一站式切除高级别脑动静脉畸形弥补单了一治疗方案的缺陷,获得了较高的即时闭塞率和相对较低的致残率和病死率。     

体感诱发电位监护下脑动静脉畸形的栓塞治疗

目的:评价在短潜伏期体感诱发电位(SSEP)监护下脑动静脉畸形(AVM)的血管内栓塞治疗(EVET)的效果。方法:回顾性分析我院收治进行EVET的31例患者的资料,其中男17例,女14例,年龄9～67岁,平均37.6岁。结果:①影像学结果:31例AVM病例中,17例(55%)行一期EVET,畸形血管团完全消失;3例行二期栓塞治疗有2例(7%)畸形血管团完全消失;2例行三期栓塞治疗,畸形血管团完全消失;9例行一期EVET时出现SEEP的明显变化,未作进一步的EVET。以最后一期栓塞后的数字减影式血管造影(DSA)资料进行栓塞程度统计:畸形血管团完全消失(100%栓塞)19例,占61%;70%～99%的栓塞7例,占23%;30%～69%的栓塞4例,占13%;≤29%的栓塞1例,占3%;②SSEP结果:术中N20波潜伏期及波幅无变化17例,5例SSEP有变化者治疗好转后作了二、三期EVET。8例出现中枢传导并N20波幅的降低,1例出现N20波消失,此9例未作进一步的EVET;③并发症:共4例,其中2例术中出现血管痉挛,1例术后出现偏瘫等神经功能损害,1例术后出现正常灌注压突破并死亡;④随访结果:良好28例,占90%...     

颅内动静脉畸形患儿血管内栓塞术后出血的危险因素分析

目的探究颅内动静脉畸形(cAVM)行血管栓塞治疗术后出血发生率及相关危险因素。方法选取2013年8月至2018年8月于我院脑外科行血管内栓塞治疗的cAVM患者180例为研究对象,观察其术后1周颅内出血发生情况,比较出血及未出血患者临床资料及畸形血管团特点,采用Logistic回归分析法探究cAVM栓塞术后出血的危险因素。结果cAVM栓塞术后出血发生率为17.78%,多于术后3 d内发生,以脑实质出血最常见。单因素分析显示,高血压史、出血史、畸形血管直径、深静脉引流、合并动脉瘤、栓塞体积、引流静脉栓塞及术后血压未达标与术后出血有关(P<0.05),而性别、年龄、癫痫史、畸形血管位置、S-M分级、栓塞时间及术后使用脱水剂与术后出血无关(P>0.05);多因素分析显示,出血史、深静脉引流及引流静脉栓塞是血管内栓塞术后颅内出血的独立性危险因素(P<0.05)。结论出血史、深静脉引流及引流静脉栓塞是cAVM栓塞术后出血的独立性危险因素,正确认识并在手术过程中采取相应的防范措施有利于降低栓塞出血并发症的发病率。     

Transarterial embolization of cerebral arteriovenous malformations: A durable treatment for venous side hemorrhage?

Cerebral arteriovenous malformations (AVMs) have been occasionally reported to bleed from their venous side. This may particularly be the case when venous ectasias or aneurysms develop in the setting of steno-occlusive venopathy. Venous side hemorrhage should be suspected when the hematoma is centered on the venous pouch or when a venous pseudoaneurysm is identified on angiography. For AVMs with an identifiable point of rupture, early treatment is recommended in an attempt to secure the weak spot and minimize the risk of rerupture. When possible, microsurgical resection is the definitive and preferred treatment. In contrast, because of its latency period, stereotactic radiosurgery does not confer immediate protection in such cases. Endovascular transarterial embolization may offer immediate cure to only a minority of small AVMs, but remains a very useful temporizing strategy for arterial rupture sites such as proximal or intranidal aneurysms, allowing to defer definitive AVM treatment by either microsurgery or radiosurgery to a later stage. However, when the rupture site is venous in location and the AVM cannot be readily cured by either microsurgery because of its location in eloquent brain or embolization because of its large size, protecting patients from early rerupture may become problematic. We propose that, by reducing flow through the AVM, transarterial embolization may lead to secondary thrombosis of venous pseudoaneurysms and confer durable occlusion of these weak spots, pending definitive AVM cure. Therefore, transarterial embolization should be routinely attempted in such difficult-to-manage cases. An illustrative clinical case is presented in support of this hypothesis.     

Primary benign vascular tumors and tumorlike lesions of the kidney: a clinicopathologic analysis of 15 cases

Primary benign vascular lesions of the kidney are uncommonly encountered in routine surgical pathology practice. They can, however, mimic malignancy or be an incidental finding adjacent to a malignancy. Fifteen specimens harboring 16 primary benign renal lymphatic/vascular lesions were identified from our files from 1999 to 2011 and subjected to a detailed pathologic evaluation and clinicopathologic correlation. Clinical and demographic data were available for all the 15 cases. There were ten males and five female patients with age range of 33?C74?years (mean 54?years). Lesions ranged from 0.5?cm to 40?cm (average, 6.6?cm). There were six arteriovenous malformations (AVMs), four hemangiomas, three anastomosing hemangiomas, two lymphangiomas, and one solid intravascular papillary endothelial hyperplasia (IPEH). Five AVMs were located in the kidney parenchyma and one in the pelviureteric system. Additional associated lesions ranged from renal stones to renal cell carcinoma in two cases (one lymphangioma and one AVM). One AVM was associated with a capillary hemangioma in the vicinity, and another with a history of renal cell carcinoma in the contralateral kidney. Capillary hemangiomas and lymphangiomas were noninfiltrative and lacked cytological atypia and mitotic activity. Except for a renal pelvic AVM, all other renal AVMs radiologically mimicked malignancy. The patients had undergone partial or radical nephrectomies except for the renal pelvic AVM which was laparoscopically excised. To the best of our knowledge, none of the cases had any syndromic/systemic associations. Benign vascular lesions of the kidney are rarely seen in routine surgical pathology practice, partly because a vast majority of them are medically treated by embolization. However, lesions mimicking renal malignancy are subjected to surgery. They may exist as isolated lesions or coexist with malignant lesions either in the ipsilateral or the contralateral kidney.     

脑动静脉畸形血流动力学的理论模型研究进展

脑动静脉畸形 (脑 AVM)可导致脑血流的异常分布 ,不正常的血流动力学状态是脑 AVM发生脑内出血和造成某些神经功能障碍以及严重的手术并发症的重要原因之一。由于脑血管内血流压力、流量等血流动力学参数测量技术的局限 ,一些学者借助于理论模型来分析脑 AVM的血流力学特征。本文介绍了国外关于脑 AVM血流动力学理论模型研究的进展 ,论述了各类模型的特点和缺陷以及进一步研究的思想路线。     

Early rerupture of cerebral arteriovenous malformations: beware the progressive hemispheric swelling

While early rerupture of cerebral arteriovenous malformations (AVMs) may not be as rare as previously thought, its determinants and risk factors remain unknown. Impairment of the venous drainage of AVMs is a well known risk factor for rupture and has been linked with the development of perinidal cerebral edema. We propose that a significant proportion of early AVM reruptures are the result of post-hemorrhagic venous drainage impairment, which may manifest as refractory perihematomal edema. To support this hypothesis, an illustrative case of early AVM rerupture occurring 3 weeks following intracranial hemorrhage and heralded by progressive perinidal and perihematomal edema is presented. This finding should be viewed as a marker for unstable lesions with a high risk of imminent rerupture and should thus prompt a rapid definitive treatment for the AVM.     

Determination of Blood Flow Velocity and Transit Time in Cerebral Arteriovenous Malformation using Microdroplet Angiography

Advancement in imaging and biomedical technology has improved the use of catheter-based transarterial embolization (occlusive therapy) of cerebral arteriovenous malformations (AVMs). Among a variety of embolic agents, liquid adhesives (acrylates) have proven to be more successful in permanent obliteration of AVMs. The use of liquid adhesives requires the experience and skill of the operator. However, acquiring accurate information on blood flow and transit times through the AVM prior to embolization can optimize the treatment. In addition, knowledge of the polymerization time and behavior of the acrylate enables a complete and safe occlusion of the arteriovenous transition within the AVM nidus. Standard commercially available iodine-based contrast agents seem to be insufficient to determine AVM transit times from angiograms. For a more accurate assessment of AVM transit times, the use of a nonsoluble contrast agent (Ethiodol) and a high-speed digital subtraction angiography (DSA) is suggested. Small amounts (<20 l) of Ethiodol were infused to create microdroplets and traced using DSA at 15 fps. Transit time, defined as the time interval required for a droplet to reach the venous part of the AVM after being flushed from the tip of the catheter, could be accurately calculated. Postprocessing was used to calculate trajectories and velocities of microdroplets. © 2001 Biomedical Engineering Society. PAC01: 8719Uv, 4755Dz, 8719La, 8759Bh     

颅内动静脉畸形14例手术治疗分析

目的：探讨颅内动静脉畸形（AVM）外科治疗的临床疗效。方法：采用开颅手术切除畸形血管团方法治疗颅内AVM14例。结果：14例中治愈13例，术后死亡1例。存活13例，11例获随访1月-10年，术后未出现新的神经功能障碍，术后未见癫痫再发作，头痛症状消失或明显减轻。结论：颅内动静脉畸形急性出血期以手术治疗为主，未出血者或病情允许的情况下，外科手术联合介入治疗疗效更佳。     

LEO+Baby单支架辅助弹簧圈栓塞前交通动脉瘤的有效性及安全性

目的评价专为小血管设计的低剖面、自膨式LEO+Baby单支架辅助弹簧圈栓塞前交通动脉瘤的有效性和安全性。方法回顾性分析应用LEO+Baby单支架辅助弹簧圈栓塞技术治疗的52例前交通动脉瘤患者的临床资料,统计患者基本信息、影像学资料、手术情况及并发症情况。结果52例前交通动脉瘤患者应用LEO+Baby支架51枚,1例患者支架导管到位困难,转开颅手术治疗,其余均操作成功,成功率为98%(51/52);术后即刻造影动脉瘤完全栓塞42例,瘤颈残留9例。术中动脉瘤破裂1例,支架内血栓形成3例,术中弹簧圈脱出1例。术后随访6~12个月,改良Rankin量表(mRS)评分为4~5分2例,2~3分5例,随访无死亡病例。46例患者术后6个月DSA复查结果显示完全栓塞率89.1%(41/46),其余5例未行DSA复查;无支架相关并发症及动脉瘤再破裂出血发生。头颅CT显示,无迟发性脑梗死、脑出血发生。结论应用LEO+Baby单支架辅助弹簧圈栓塞前交通动脉瘤操作成功率和安全性高、围术期并发症少且短期预后良好。     

Management of Bleeding Uterine Arteriovenous Malformation with Bilateral Uterine Artery Embolization

Purpose

To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM).

Materials and Methods

Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies.

Results

A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure-related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term.

Conclusion

Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.