脑动静脉畸形出血危险因素的研究

目的探讨脑动静脉畸形（ＡＶＭ）出血的危险因素。方法统计２８４例ＡＶＭ的数字减影脑血管造影所示病灶的解剖部位和大小、引流静脉的数目和类型，测定１８例供血动脉平均压力和以经颅多普勒超声检查７４例血流动力学参数，并分出血组和非出血组进行比较。结果小病灶、深部病变、单支静脉引流和深静脉引流者出血发生率显著增高，出血组病灶供血动脉平均压力高于非出血组，而血流速度则低于非出血组。结论脑ＡＶＭ出血与病变的大小、部位、引流静脉的类型和数目、供血动脉的压力及血流速度有关     

脑动静脉畸形动物模型的初步建立

目的：建立脑动静脉畸形（ＡＶＭ）动物模型。方法：以中国实验用小型猪的颅底微血管网（ｒｅｔｅｍｉｒａｂｉｌｅ）为畸形团，经颈动静脉吻合等建立脑ＡＶＭ动物模型；用ＮＢＣＡ胶和Ｅｍｂｏｓｐｈｅｒｅ颗粒分别栓塞；模型建立和栓塞前后行血管造影。结果：成功构建了具有供血动脉、畸形团和引流静脉的ＡＶＭ模型；造影动脉期显示血液经畸形团向引流静脉分流；栓塞时，胶在畸形团（微血管网）里弥散、聚合良好，颗粒可使其显影逐渐变淡、直至消失。结论：本方法对建立脑ＡＶＭ急性期动物模型更简单经济省时，并且可靠；该模型在血管结构，造影影像和栓塞行为上与人脑ＡＶＭ相似，适用于有关的研究和介入医师的培训。     

脑动静脉畸形的流量和供血动脉压力测定

根据经颅多普勒超声和血管造影的数据资料，对６３例脑动静脉畸形（ＡＶＭ）的分流量进行计算，并通过微导管测量了１５条供血动脉内的压力。结果显示ＡＶＭ的动静脉分流量在出血组为２７２±２４５ｍｌ／ｍｉｎ，非出血组为８７６±４３３ｍｌ／ｍｉｎ（Ｐ＜０．０１）。不同供血动脉的压力差别很大０．６～１０ｋｐａ（５～７５ｍｍＨｇ），出血组为６．２±１．９ｋＰａ，癫痫组为２．５±１．２ｋｐａ（Ｐ＜０．０１）。认为脑ＡＶＭ出血的血液动力学因素为相对的高阻力低流量，流量和压力分析尚可有助于预警“正常灌注压突破”综合征的发生。     

脑动静脉畸形的供应动脉及导出静脉与出血危险性的关系

本文通过分析５０例脑动静脉畸形（ＡＶＭ）的全脑数字减影血管造影（ＤＳＡ）资料及手术探查结果，探讨ＡＶＭ的深、浅及供血、引流血管数量与出血发生率的关系。经统计比较发现：深部较浅部ＡＶＭ出血率高；供应动脉条数多于导出静脉条数者及仅有单条导出静脉出血率最高，并与其他组有显著性差异（Ｐ＜０．０５、Ｐ＜０．０１）。因此，我们认为：在临床工作中对这些ＡＶＭ患者应给予足够的重视。     

颅内动静脉畸形血管内栓塞治疗并发症分析

报告６０例颅内动静脉畸形（ＡＶＭ）血管内治疗后所产生的并发症。指出并发症的产生主要归结于：（１）误栓正常动脉或脑供血动脉分布到正常脑组织的分支被栓塞，产生新的神经功能缺失；（２）栓塞剂经脑ＡＶＭ瘘口将引流静脉栓塞造成畸形血管破裂出血；（３）一次过多栓塞了大型高流量ＡＶＭ，使原有症状加重。文中针对上述并发症产生的原因，结合病历探讨一些防治措施。     

脑动静脉畸形出血危险因素的Cox回归分析

目的：探讨与脑动静脉畸形（ＡＶＭ）出血相关的临床及血管影像学特征，以期对脑ＡＶＭ的出血倾向作出评价和预测。方法：应用Ｃｏｘ回归模型，对５９例脑ＡＶＭ进行出血危险因素的单因素及多因素分析。结果：５９例脑ＡＶＭ中，观察期内出血４８例（占８１％），年平均出血率为２％；病灶大小、供应动脉支数以及引流静脉支数是决定脑ＡＶＭ出血倾向最重要的危险因素；小型ＡＶＭ、多支动脉供应的ＡＶＭ以及仅有单支静脉引流的ＡＶＭ最易破裂出血。结论：建议脑血管造影时着重对此三项指标进行描述；对于出血风险较大的脑ＡＶＭ应及早治疗。     

3D—CTA,MRA和DSA对脑动静脉畸形成像的对照性研究

目的：评价数字减影血管造影（ＤＳＡ）、三维计算机断层扫描血管造影（３Ｄ－ＣＴＡ）和磁共振血管成像技术（ＭＲＡ）对于脑动静脉畸形（ＡＶＭ）甩像的价值。方法 ４３例ＡＶＭ前瞻性对照研究,结果 ３Ｄ－ＣＴＡ阳性率１００％,与ＤＳＡ比较;供血动脉的来源,数目和形态１００％吻合,引流静脉３３例完全吻合（７８．６％）,９例部分吻合（２１．４％）;病灶部位、大小以及深度１００％吻合。ＭＲＡ阳性率９５．８％,１例假阴性（４．２％）。与ＤＳＡ影像比较,供血动脉１７例完全吻合（７０．８％）,６例部分吻合（２５．０％）;引流静脉１４例完全吻合（５８．３％）,９例部分吻合（３７．５％）,病灶部位、大小以及深度９８．５％吻合。结论 ＤＳＡ是脑ＡＶＭ成像的“金标准”。３Ｄ－ＣＴＡ和ＭＲＡ技术的发展为ＡＶＭ影像不诊断提供了高准确性,无创性的     

脑动静脉畸形的静脉引流特征与出血危险性相关研究

本文对经过脑血管造影证实的５２例脑动静脉畸形（ＡＶＭ）的静脉引流特征与出血危险性的相关关系进行了研究。结果表明，脑ＡＶＭ的引流静脉数目与出血危险性呈负相关（Ｐ〈０．０５），引流静脉数目减少，出血率越高，越多出血率越少；引流静脉无早现的ＡＶＭ比早现的ＡＶＭ出血率高（Ｐ〈０．０１）；；引流静脉无或轻度扩张的ＡＶＭ的出血率明显高于有明显扩张的ＡＶＭ（Ｐ〈０．０５）；深静脉引流的脑ＡＶＭ出血率高，浅静脉引     

偏头痛患者的rCBF和TCD研究

采用＾１３３氙吸入法测量局部大脑血流量（ｒＣＢＦ）和经颅多普勒超声（ＴＣＤ），对６４例固定一侧偏头痛患者进行了ｒＣＢＦ及脑大动脉的最大平均血流速度（ＭＦＶ）、脉动指数（ＰＩ）联合研究。研究结果倾向该症血流变化为交感－末梢动脉阻力调节紊乱学说，而不支持ＭＣＡ扩张２０％的推理。     

血管内栓塞和手术切除大型脑动静脉畸形

本文报道用栓塞和手术切除治疗１２例大型和功能区的脑动静脉畸形（ＡＶＭｓ），并与单纯手术治疗相比，结果表明，对单纯手术切除危险性较高的脑ＡＶＭｓ，用血管内栓塞后手术切降可明显降低术中出危险及术后致残率和死亡率。其理由为：（１）术前栓塞可阻断供血动脉摁流，使病灶缩小，有利于术中病灶暴露分离，避免和减轻对周围脑组织损伤；（２）术前栓塞可使高流量的ＡＶＭｓ血流量减少，防止单纯手术切除后产生脑灌注压急剧升高     

脑动静脉畸形的多普勒超声研究

本文报道经颅多普勒超声(TCD)研究29例脑动静脉畸形(AVM)的血流动力学改变,50％小型AVM供血动脉的流速正常,50％小型AVM和大中型AVM供血动脉的流速均增快;中型AVM同侧颅外颈内动脉(PICA)流速增快,大型AVM双侧PICA流速均增快。AVM切除后供血动脉流速均减慢、脉动指数(PI)增大,其中中型AVM同侧PICA流速减慢,大型AVM双侧PI-CA流速均减慢且双侧颅内非AVM供血动脉的舒张末期流速减慢和PI增大。3例大型AVM手术中或手术后发生脑血流过度灌注现象。     

Evaluation of blood supply dynamics and possibilities of cerebral arteriovenous malformations (AVM) imaging by means of transcranial color-coded duplex sonography (TCCS)

The present study was carried out in 12 patients (7 males and 5 females) aged 16-56 years (mean age 35.9) with arteriovenous malformation diagnosed in cerebral angiography. The examination was performed by means of ATL ULTRAMARK 9 with low-frequency (2MHz to 3MHz) transducer. Assessment was made of possibilities of imaging arteriovenous malformations by transcranial colour-coded duplex sonography and of blood flow values in the studied intracranial arteries. Statistical analysis was applied of the following blood flow parameters: mean velocity, peak systolic velocity, end diastolic velocity, pulsatility index (PI), resistance index (RI), pulsatility transmission index (PTI) and relative flow velocity (RFV). The malformations were imaged using TCCS in 9 (75%) patients. In two-dimensional B mode image the angiomas displayed echogenicity similar to the surrounding brain parenchyma and could not be precisely delineated. The colour-coded imaging made possible depicting the image of the vessel loops in the AVM nidus. In two other patients the presence of angiomas was confirmed by blood flow disturbances in the feeder vessel: increased blood flow, decreased pulsatility and resistance indices, and collateral circulation. Collateralization by the contralateral internal carotid artery via the anterior communicating artery was disclosed in 9 cases. The TCCS results corresponded closely to angiographic findings. Collateral circulation via the posterior communicating artery ipsilateral to the AVM was found in 3 of 5 patients in whom it was diagnosed in cerebral angiography. Doppler findings in the patients were similar to the conventional TCD examination. In the feeding vessels significant increase in blood flow velocity and decreased pulsatility and resistance indices was observed. RFV value for the end diastolic velocity was higher than RFV for the peak systolic velocity (p < 0.001) and mean velocity. These findings suggest that the increased end diastolic velocity in the feeding vessel is higher than the mean velocity and peak systolic velocity. It is thought that the TCCS can be successfully used in early diagnosis of cerebral arterio-venous malformations and as an instrument in follow-up examination.     

Haemodynamic changes in arteriovenous malformations induced by superselective embolization: transcranial Doppler evaluation

To reduce the intraoperative and postoperative complications in patients who suffer intracerebral arteriovenous malformations (AVM’s), the slow reduction of the shunt flow to a brain perfusion flow has been tried by the use of several methods: microsurgical techniques, selective and superselective embolization, intraoperative embolization, staged operation. The risk of re-bleeding and intraoperative oedema increases in AVM’s with two or more feeders. Our policy was to exclude such AVM’s by primary superselective embolization??. If there was only a small residual angioma, we tried to remove this by microsurgical techniques. The haemodynamics in AVM’s could be examined by measuring the blood flow velocities in the feeding arteries and in the other parts of the circle of Willis by transcranial Doppler sonography (TCD). Signs of haemodynamic effective embolization could be measured by the reduction of flow velocities. After exclusion of an AVM the velocities in the brain and feeding arteries decreased to below normal values in the first days after the operation. In the feeding arteries this was due to the fact that the arteries were enlarged so that the velocity must be decreased when there was normal volume flow. The combination of superselective angiography and microsurgical resection of the residual angioma seemed to be the best way to treat AVM’s which are fed by more than two arteries and which are 3 or more cm in diameter. TCD investigations were used to measure the haemodynamic changes before and after angioma superselective embolization and microsurgical operation.

?? Service Neuroradiologie, Paris: (J.J. Merland).     

Arteriovenous Malformation with an Occlusive Feeding Artery Coexisting with Unilateral Moyamoya Disease

Background

Arteriovenous malformations (AVMs) with vascular abnormalities, including aneurysms, have been reported frequently. However, the coexistence of AVM and unilateral moyamoya disease is rare. We report herein an AVM patient who presented with acute ischemic stroke with unilateral moyamoya disease and occlusion of the feeding artery.

Case Report

A-41-year old man was admitted with sudden dysarthria and facial palsy. Brain computed tomography and magnetic resonance imaging revealed an acute infarction adjacent to a large AVM in the right frontal lobe. Cerebral angiography revealed occlusions of the proximal right middle cerebral and proximal anterior cerebral arteries, which were the main feeders of the AVM. Innumerable telangiectatic moyamoya-type vessels between branches of the anterior cerebral artery and dilated lenticulostriate arteries on the occluded middle cerebral artery were detected. However, a nidus of the AVM was still opacified through the distal right callosomarginal artery, which was supplied by the remaining anterior cerebral artery and leptomeningeal collaterals from the posterior cerebral artery.

Conclusions

While AVM accompanied by unilateral moyamoya disease is rare, our case suggests an association between these two dissimilar vascular diseases.     

A case of a large neonatal arteriovenous malformation with heart failure. Color Doppler sonography,MRI and MR angiography as early non-invasive diagnostic procedures

We report a case of a large arteriovenous malformation (AVM) of neonatal onset with heart failure. Transfontanel color Doppler sonography revealed abnormal vessels in the early stage of the investigation. Magnetic resonance imaging (MRI) revealed numerous flow voids suggesting abnormal vessels, and magnetic resonance angiography (MRA) disclosed numerous bizarre abnormal vessels. Color Doppler sonography is a convenient and appropriate procedure for the early bedside diagnosis of neonatal AVMs. MRI and MRA can replace cerebral angiography for the diagnosis of neonatal AVMs.     

彩色经颅多普勒超声在脑血管疾病中的应用

目的研究不同脑血管病的血流动力学特征,探讨彩色多普勒超声对脑血管疾病诊断及疗效评估的应用价值。方法采用彩色经颅多普勒超声探测不同脑血管病并与DSA对照。结果实际探测985例脑血管病人,其中脑动静脉畸形240例,颅内动脉瘤409例,颈动脉海绵窦瘘113例,烟雾病148例,硬脑膜动静脉瘘75例,其检测结果与DSA符合率分别为92.9%、68.9%、100%、100%、85.3%。结论彩色经颅多普勒超声能实时直观地显示颅内及颈部血管血流状况,更全面、准确地提供颅内血流动力学信息,是脑血管病无创检测的重要手段之一。     

237例脑动静脉畸形的彩色经颅多普勒超声检测与DSA比较分析

目的探讨彩色经颅多普勒超声无创诊断脑动静脉畸形（AVM）的临床应用价值。方法采用Acuson Sequoia512型彩色多普勒超声诊断仪,电子相控阵变频探头,使用频率2.0MHz,经颞窗、枕窗探测颅底主要血管及部分分支血管,了解各血管血流动力学改变以及AVM大小、部位、供血分支、引流静脉及颅内盗血情况,并与DSA检查结果进行比较分析。结果237例中除18例因透声窗不满意检测失败外,实际检测219例,其中明确诊断176例,可疑25例,未见明显异常18例,与DSA比较其总检出率为92%。结论彩色经颅多普勒超声能实时、动态观察畸形血管团及供血动脉血流动力学改变,了解引流静脉及颅内盗血情况,准确提供颅内血流动力学参数,因而可作为脑AVM诊断、疗效评估及随访的一种无创性检查手段。     

介入技术结合手术建立简易绵羊脑动静脉畸形模型的初步研究

目的 应用介入技术和手术,无须手术吻合,制作简单铁急性脑动静脉畸形动物模型。方法 两个6F导管鞘,分别插入绵羊一侧颈总动脉和颈外静脉,一段输血管连通两个导管鞘,形成类似手术吻合的颈动静脉瘘,夹闭颈总动脉近心端,夹闭或不夹闭颈外静脉远心端;连接前和连接后分别做对侧颈动脉造影,以证实血流的方向,结果 6只绵羊 全部形成以造瘘对侧颌内动脉为“供血动脉”,以两侧颅底微血管网为“畸形团”,造瘘侧颌内动脉为“引流静脉”的AVM模型,结论 以介入技术为主要方法建立动静脉瘘,效果相当于手术,其优点为节约时间,操作简单,可应用于急性AVM的实验研究,更适用于介入治疗技术的培训。     

Cerebral blood-flow velocity patterns in post-hemorrhagic ventricular dilation

To evaluate the effect of ventricular dilation (VD) on cerebral hemodynamics, serial cerebral blood-flow velocity patterns from the anterior and middle cerebral, and circle of Willis arteries were examined by rangegated, pulsed Doppler sonography in premature infants developing post-hemorrhagic VD. Nine infants (25 to 30 weeks gestation) without a patent ductus arteriosus were studied until resolution of VD. Forty-nine cranial sonograms from all nine infants were reviewed independently and grouped cross-sectionally into mild, moderate and severe VD prior to shunt. The corresponding pulsatility index (PI) showed a consistent trend of increase with VD in all three studied vessels. In six infants, absent or reversed diastolic flow was observed at the height of VD. Four of these infants required V-P shunt. Immediate fall in PI occurred in all three vessels. Serial measurement of PI during VD reflects global changes in cerebrovascular resistance. Results confirmed PI could be a useful index in monitoring cerebral hemodynamic changes.     

稳定型高流量脑动静脉畸形动物模型的建立

目的探讨建立稳定性、高流量的脑动静脉畸形（AVM）动物模型的方法,为人脑AVM的临床研究提供帮助。方法将实验用小型猪40头按随机数字表法随机分实验组和对照组,每组20头。以猪的颅底微血管网（RM）为畸形血管团,行左侧咽升动脉（L-APA）与左侧颈外静脉（L-EJV）的端端吻合,结扎同侧颈外动脉（L-ECA）、L-APA降支和左侧枕动脉（L-OA）降支。实验组造模前1 d及造模后即刻、造模后7、14、21和28 d股静脉注射一氧化氮合酶抑制剂L-NAME（250 mg/kg）。造模术前1 d及造模后即可、造模后21 d、28 d、2月和3月行脑血管造影检查和经颅多普勒超声（TCD）检测右侧颈总动脉（R-CCA）、右侧APA（R-APA）、右侧颈外动脉（R-ECA）、右侧颈内动脉（R-ICA）、RM、左侧颈内动脉（L-ICA）、L-APA和L-EJV端端吻合的引流静脉,测量平均峰值血流速度（APV）及峰值流速差、频谱、博动指数（PI）、脑血流量（CBF）、血流方向（BD）以及R-APA压力、L-APA-EJV压力和二者之间压力差。结果两组均造模成功,BD由右侧流向左侧。实验组APV峰值流速差、频谱、PI和CBF明显高于对照组（P〈0.05）,实验组R-APA压力明显增加（P〈0.05）,L-APA-EJV压力明显减低（P〈0.0）。结论以R-CCA、R-APA、R-ECA、R-L-ICA为供血动脉、以RM为畸形血管团、以L-APA-EJV为引流静脉可成功建立稳定性、高流量脑AVM动物模型。