脑动静脉畸形经立体定向放射治疗后不同时期的组织病理变化

目的研究脑动静脉畸形(AVMs)经立体定向放射治疗后不同时期的组织病理变化。方法对10例脑AVMs立体定向放射治疗后的病理标本进行苏木精-伊红染色,并用平滑肌肌动蛋白(SMA)、血管内皮生长因子(VEGF)及神经胶质酸性蛋白等抗体进行免疫组化研究。结果经立体定向放射治疗后,早期脑AVMs血管病理变化包括内膜层与血管壁分离,细胞外基质增生;中期可见平滑肌细胞增生,血管壁增厚,管腔狭窄至消失,管壁玻璃样变;晚期病理变化包括血管壁进行性增厚,在完全玻璃样变的区域细胞核固缩。早期放射反应的动脉管壁中VEGF呈阳性表达,在中期放射反应的动脉管壁中SMA呈强阳性表达。结论立体定向放射治疗后脑AVMs血管中层的平滑肌细胞增生和变性是血管闭塞的关键因素。     

直线加速器放射外科治疗脑血管畸形的临床评价

报告采用立体定向放射外科方法治疗脑血管畸形３０例。８０％等剂量区的靶剂量设计为１５～２０Ｇｙ。在１～２年内畸形血管团完全及次全闭塞率为６７％。１例放疗后６个月死于再出血，其余病人随访期间均未发现再出血。癫痫为首发症状者其控制率达８１．８％。４例出现后期放疗反应，表现为较广泛的白质水肿，其中２例开颅手术，切除的畸形血管均已闭塞。本文就放射外科治疗后再出血、癫痫控制以及其他神经系统反应等有关问题进行讨论。     

经放射外科未全治愈的大型动静脉畸形的手术切除

大量文献报道立体定向放射外科(γ—刀和χ—刀)治疗颅内动静脉畸形(AVMs)成功率高,并发症少,但该治疗方法尚有局限性,包括较大的AVMs管腔闭合率低,高危的放射并发症以及血管完全闭合之前有颅内出血的可能。 作者1990—1994年间手术切除放射外科治疗后1—11年未完全闭塞的AVMs33例,年龄7～64岁,男13例,女20例,放射治疗前AVMs体积依MRI和血管造影测得为0.8—117cm~3,平均21.6cm~3,10例AVM位于语言、运动、感觉和视觉中枢,11例位于基底节或丘脑,1例位于脑干,1例位于丘脑,1例位于小脑。3例位于胼胝体,6例位于非功能区。深静脉引流13例,表浅静脉引流12例,两种方法皆用8例。Spetzler—Martin分     

直线加速器放射外科治疗脑血管畸形的临床评价

报告采用立体定向放射外科方法治疗脑血管畸形３０％。８０％等剂量区的靶剂量设计为１５－２０ＧＹ。在１－２年内畸形血管团完全及次全闭塞率为６７％。１例放疗后６个月死于出血，其余病人随访期间均未发现再出血。癫痫为首发症状者其控制率灰８１．８％。４例出现后期放疗反应，表现为较广泛的白质水肿，其中２例开颅手术，切除的畸形血管均已闭塞。     

脑动静脉畸形立体定向放射外科治疗后的出血危险

脑动静脉畸形(AVM)的处理主要目的是消除颅内出血的危险。立体定向放射外科对直径<3cm的AVMs,术后2～3年中畸形血管闭塞率达80％。但其主要缺点是术后AVM在闭塞过程中仍存在出血危险。而这种危险是增加、减少或无变化均不能明确预测。为此,作者回顾性研究了一组放射外科病例的治疗体会。     

脑动静脉畸形的立体定向放射外科治疗

立体定向放射外科治疗脑动静脉畸形已有20余年的历史,临床应用的有γ—刀、经改装的直线加速器(X—刀)和粒子射线等。治疗后畸形血管可发生管壁胶原纤维增生、管腔狭窄和闭塞,一般发生在1—2年后,手术难治的动静脉畸形如位于功能区及脑深部者是其适应症     

微导管血管内真丝线段治疗脑动静脉畸形的并发症(附12例报告)

我科自1991年至1995年共对33例脑动静脉畸形(AVMs)进行血管内丝线段栓塞治疗,12例发生各类并发症.本文对并发症的发生原因、治疗及预防等问题进行了讨论.1 对象与方法1.1 一般资料 男9例,女3例.年龄6～47岁.额叶AVMs4例,顶叶4例,颞叶2例,枕叶及丘脑各1例.1.2 操作方式 采用Seldinger技术经股动脉插管达颈内动脉,造影后更换导引管,从导引管中插入Magic微导管至畸形血管中.选择造影确定位置后通过导管注入丝线段直至畸形血管团闭塞为止.     

脑动静脉畸形的栓塞和放射外科治疗

本文作者报道了125例手术条件不良或拒绝手术的脑动静脉畸形(AVMs)病人在放射外科治疗前行栓塞治疗.全组病例中81%有出血史.22.4%的病人曾在其它单位进行过治疗.按照Spetyer-Martin脑AVMs分级标准:Ⅱ级9.6%.Ⅲ级31.2%.Ⅳ级30.4%.Ⅴ～Ⅵ级28.8%.多数病人应用了氰酯进行栓塞.62例由作者应用直线加速器进行放射外科治疗,34例在其它单位行放射外科治疗.栓塞治疗后脑AVMs完全闭塞者为11.2%,体积缩小者占76%.放     

脑动静脉畸形栓塞治疗后的组织病理及免疫组化研究

目的研究脑动静脉畸形(CAVM)栓塞治疗后的组织病理变化。方法分析11例栓塞治疗后再行手术切除CAVM的病例资料,应用增殖细胞核抗原(PCNA)、α-平滑肌肌动蛋白(α-SMA)、骨桥蛋白(OPN)、血管内皮生长因子(VEGF)等抗体进行免疫组化研究。结果栓塞后,CAVM血管腔内出现不同程度的血管炎性反应,部分被栓塞的血管腔内可见再通。栓塞治疗后的新生内膜中OPN及α-SMA呈阳性染色;畸形血管团周围组织中发现异常微血管,其内皮细胞PCNA阳性染色率高,且VEGF呈阳性染色。畸形血管周围组织中的血管内皮细胞增殖指数(19.6%±8.4%)高于对照组(10.1%±6.2%),差异有统计学意义(P<0.05)。结论栓塞材料引起血管呈不同程度的炎性反应,适度的血管反应有助于管腔闭塞;栓塞治疗后畸形血管周边有微血管增生现象。     

脑动静脉畸形伽玛刀治疗后的组织病理研究(附5例报道)

目的研究脑动静脉畸形(CAVM)经伽玛刀治疗后的组织病理变化。方法对5例CAVM伽玛刀治疗后的病理标本进行HE染色,并用α-SMA、PCNA、OPN及VEGF等抗体进行免疫组化研究。结果伽玛刀治疗后CAVM血管病理变化包括内膜增厚,管壁增厚、玻璃样变,管腔狭窄至消失等。玻璃样变的管壁或闭塞的管腔可见管腔的再通。OPN、PCNA在表现为早期放射反应的动脉管壁中有强表达;1例标本见内皮细胞PCNA及VEGF阳性染色的网状毛细血管样血管。结论放射治疗后CAVM血管中层的VSMC增生,部分转变为合成表型。VSMC的迁移、增殖和变性是伽玛刀治疗后CAVM进行性血管病理变化的关键因素。     

Transplacental induction of myeloschisis associated with hindbrain crowding and other malformations in the central nervous system in Long-Evans rats

Nine groups of 66 pregnant rats, grouped by gestation days 11 to 19, were subjected to a single, intragastric administration of ethylenethiourea (ETU). Cesarean section was performed on gestation day 20. No dam died following the ETU treatment, although a mortality as high as 21.2% was noted among the fetuses in this group; the remaining live fetuses were found to suffer from a high incidence of myeloschisis associated with hindbrain crowding. Exencephaly and abnormally enlarged head with occipital bossing due to the herniation of the mesencephalic tectum, with and without dilation of the mesencephalic and 4th ventricles, were induced among the fetuses of the dams given ETU at gestation days 12 and 13. Various degrees of hydranencephaly and dysplastic hydrocephalus were found among the fetuses of dams treated by ETU from gestation days 14 to 18. From the histological features of these malformations of the central nervous system (CNS), a possible mechanism in the induction of myeloschisis with hindbrain crowding induced by ETU is discussed, and compared with the previously reported similar malformations induced by trypan blue.Presented at the 12th Scientific Meeting of the International Society for Paediatric Neurosurgery, Cairo, 1984     

Spinal arteriovenous malformations

The overall function, pain and mood disturbances of 19 patients with spinal arteriovenous malformations (AVM), treated by embolization between 1983 and 1988, were studied. The after-care had taken place in different hospitals and clinics. The patients demonstrated markedly poorer physical function (Sickness Impact Profile) and poorer psychological well-being (Mood Adjective Check List) than control population samples and a comparison group of traumatic incomplete paraplegies. The degree of decrease of mood levels implied possible depressive disorder (Hospital Anxiety and Depression scale) in 16% of the patients and differed from that of the paraplegic comparison group. Furthermore, the AVM patients reported more disturbance of their family and social life than the paraplegics and they were more seldom gainfully employed. Patients recorded a wide range of pain scores, significantly worse than the paraplegics, and their pain was closely linked to overall quality of life (QL) perception. The QL scores were consistently related to all measures of functional and emotional status, but no connection with neurological lesion levels or medical complications was found. Specialised programmes after embolization, such as those offered in spinal injury units, would appear appropriate for AVM patients to improve their physical functioning and to provide a more rewarding social life.     

97例脑动静脉畸形临床分析

目的:报道97例脑动静脉畸形临床分析。方法:外科手术、血管内栓塞治疗、伽玛刀(γ-刀)治疗和保守治疗。结果:手术治疗66例,优良率81.9％,病残率15.1％,手术死亡率3％。血管内栓塞治疗25例,其中栓塞100％4例,栓塞70％～95％12例,栓塞50％～70％5例,栓塞50％以下4例。3例行γ—刀治疗,3例保守治疗。有7例于手术后、4例于栓塞后行放射治疗。结论:作者认为提高脑动静脉畸形的治愈率,降低病残率及死亡率的关键在于不同部位、类型的脑动静脉畸形选择恰当的治疗方案,对各种治疗方法的适应证进行讨论。     

Vascular complications of stereotactic radiosurgery for arteriovenous malformations

Objective

Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience.

Methods

Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies.

Results

After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3 cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage.

Conclusion

While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.     

脑动静脉畸形的血管内栓塞治疗

应用国产NBCA经血管内栓塞治疗脑AVM 32例,效果满意.讨论了NBCA的特点、栓塞的适应证、栓塞导管的置入技术、栓塞剂的配制、栓塞技术要点及栓塞后并发症的防治等问题.     

Neurosurgical management of congenital malformations of the brain

Congenital malformations encompass a diverse group of disorders that often present at birth, either as the result of genetic abnormalities, infection, errors of morphogenesis, or abnormalities in the intrauterine environment. Congenital disorders affecting the brain are now often diagnosed before delivery with the use of prenatal ultrasonography. Over the past several decades, there have been major advances in the understanding and management of these conditions. This review focuses on the most common cranial congenital malformations, limiting the discussion to the neurosurgically relevant aspects of arachnoid cysts, pineal cysts, Chiari malformations, and encephaloceles.     

Maternal valproate dosage and foetal malformations

OBJECTIVE- To study the possible dose dependence of the foetal malformation rate after exposure to sodium valproate in pregnancy METHODS- Analysis of records of all foetuses in the Australian Registry of Antiepileptic Drugs in Pregnancy exposed to valproate, to carbamazepine, lamotrigine or phenytoin in the absence of valproate, and to no antiepileptic drugs. RESULTS- The foetal malformation rate was higher (P<0.05) in the 110 foetuses exposed to valproate alone (17.1%), and in the 165 exposed to valproate, whether alone or together with the other antiepileptic drugs (15.2%), than in the 297 exposed to the other drugs without valproate (2.4%). It was also higher (P<0.10) than in the 40 not exposed to antiepileptic drugs (2.5%). Unlike the situation for the other drugs, the malformation rate in those exposed to valproate increased with increasing maternal drug dosage (P<0.05). The rate was not altered by simultaneous exposure to the other drugs. Valproate doses exceeding 1400 mg per day seemed to be associated with a more steeply increasing malformation rate than at lower doses and with a different pattern of foetal malformations. CONCLUSIONS- Foetal exposure to valproate during pregnancy is associated with particularly high, and dose-dependent risks of malformation compared with other antiepileptic drugs, and may possibly involve different teratogenetic mechanisms.     

脑动静脉畸形的介入治疗

应用国产医用真丝段行血管内栓塞治疗脑动静脉畸形33例。所有病例均行选择性全脑血管造影,取得主要供血动脉后,采用Magic1．8F微导管超选择进入大脑前、中动脉直至病灶内。栓塞剂为5／0真丝线段,栓塞至畸形血管团消失或减少。本组栓塞后临床症状改善显著,显示了介入放射学的优越性。