脑动静脉畸形出血相关的血管构筑因素研究

目的通过对脑动静脉畸形（AVM）DSA造影特点与出血因素的研究，为判断出血的危险性及为临床选择治疗方案提供依据。方法对我院行血管内栓塞治疗脑AVM80例（其中颅内出血49例）进行分析，了解脑AVM畸形团的大小、部位、供血动脉的类型、引流静脉数目及路径、AVM合并动脉瘤等因素与脑出血的关系。结果脑AVM中、小型畸形团出血危险性高于大型；脑深部基底节和后颅凹的AVM出血的危险性比大脑皮层的AVM大；脑穿支供血动脉和椎动脉供血的AVM出血危险性大；脑AVM引流静脉数越少出血的危险性越高，而引流静脉路径与出血无明显关系；脑AVM合并动脉瘤易出血。结论脑AVM出血与血管构筑因素有关，根据血管不同构筑因素，判断脑AVM出血的可能性，为血管内栓塞治疗提供指导。     

脑血管畸形破裂出血的影响因素分析

目的 分析脑血管畸形患者发生出血的影响因素,为防治出血的发生提供诊治依据. 方法 回顾性分析吉安市中心人民医院神经外科自2002年1月至2012年1月收治的126例脑血管畸形患者的影像学资料,根据其是否发生出血分为出血组和未出血组,结合畸形血管团大小、位置,引流静脉方向、数目,供血动脉位置,合并动脉瘤数目、与畸形血管团位置关系,有无合并瘤样变等因素进行多因素Logistic回归分析和受试者工作特征(ROC)曲线分析,并比较各影响因素的曲线下面积(AUC),评价各影响因素对脑血管畸形破裂出血的预测价值. 结果 单因素分析显示畸形血管团大小、引流静脉方向、供血动脉位置、合并动脉瘤数目、合并瘤样变、与畸形血管团位置关系在出血组和未出血组间比较差异有统计学意义(P＜0.05).多因素Logistic回归分析及ROC曲线分析显示畸形血管团(OR=0.218,P=0.012)、引流静脉方向(OR=8.023,P=0.004)、合并动脉瘤(OR=6.539,P=0.029)是脑血管畸形患者发生出血的影响因素,AUC值分别为0.674、0.897、0.729.结论畸形血管团大是患者发生出血的保护因素,深部静脉引流、合并动脉瘤是患者发生出血的危险因素；引流静脉方向对患者发生出血的预测价值最高.     

颅内动-静脉畸形

<正>颅内动-静脉畸形(AVM)是脑血管畸形的最常见类型。主要由供血动脉、相互缠绕且管径不同的畸形血管团和扩张的引流静脉组成。脑实质(软脑膜)型动-静脉畸形的基底位于脑表面,呈楔形,尖端指向脑室,畸形血管团内可见神经胶质增生、无功能的脑组织、陈旧性出血和营养不良性钙化。数字减影血管造影术(DSA)是诊断的"金标准",典型征象包括动脉期显影的畸形血管团、扩张的供血动脉和引流静脉(图1a),可伴动-静脉瘘(动脉期静脉显影),供血动脉可扩张形成动脉瘤,引流静脉可扩张形成静脉湖。CT扫描未合并出血的病灶多呈等或稍高密度,部分可见条形或斑片样钙化,边界不清,若合并急性期出血     

脑动静脉畸形破裂出血的相关因素分析

目的 :探讨脑动静脉形 ( AVM)破裂出血的相关因素。方法 :通过收集本院自 1 985至 1 999年经手术证实的 95例 AVM,回顾性地分析术中所见的 AVM血管的特点 ,通过对具有不同特点的 AVM发生出血率的比较 ,研究造成 AVM破裂出血的相关因素。结果 :由于 AVM的大小、位置、是否并发动脉瘤、引流静脉的数目、通畅程度、引流去向等因素的不同 ,出血的发生率存在着明显的差异。结论 :AVM是否发生出血与供血动脉是否并发动脉瘤、畸形血管团的大小、位置、引流静脉的数目、通畅程度、引流去向等因素密切相关。总结此规律 ,今后当发现AVM存在发生出血的危险因素时应及时处理以避免出血的发生。     

出血性脑动静脉畸形合并动脉瘤的栓塞治疗

目的 探讨出血性脑动静脉畸形合并动脉瘤的特点与血管内治疗的方法.方法 经CT或MRI确认脑出血的病例,经全脑血管造影证实为脑动静脉畸形(AVM)合并动脉瘤为36例患者,根据AVM病灶和动脉瘤的特点,采取不同的栓塞策略,经血管内超选择应用α氰基丙烯酸正丁酯、ONYX胶或弹簧圈栓塞畸形团和动脉瘤.结果 栓塞后35例动脉瘤完全栓塞,AVM病灶完全消除26例;1例残留AVM因引流静脉狭窄术后1年发生出血,行血肿清除并AVM病灶切除术治愈;另1例因残余病灶接受伽玛刀治疗3个月时发生出血,保守治疗后行2次栓塞治愈.结论 AVM病灶内或病灶旁存在动脉瘤是引起脑出血的重要原因,在栓塞前制定栓塞策略,优先处理动脉瘤样病变对防止脑出血有重要意义.     

脑动静脉畸形破裂出血并血肿形成急诊手术治疗

目的 探讨脑动静脉畸形破裂出血并血肿形成急诊手术治疗的特点.方法 回顾分析我院21例脑动静脉畸形(AVM)破裂出血并血肿形成急诊手术治疗的病历资料.病变位于额叶4例,顶叶2例,颞叶7例,枕叶2例,小脑半球3例,基底节区3例.结果 血肿清除加AVM全切除12例;血肿清除加供血动脉夹闭、部分AVM畸形血管团切除3例;单纯血肿清除或脑室引流加AVM II期治疗5例(包括手术切除、介入栓塞及γ-刀治疗).结论 脑动静脉畸形破裂出血并血肿形成,出现神经系统症状恶化者需急诊清除血肿同时切除畸形血管团,而对位于功能区、脑深部或巨大AVM破裂出血并血肿形成者,在安全的前提下应尽可能的夹闭供血动脉及尽可能多的切除AVM畸形血管团,否则,仅清除血肿,待病情稳定后Ⅱ期治疗.     

颅内动静脉畸形合并动脉瘤的血管内治疗

目的 总结血管内治疗颅内动静脉畸形(AVM)合并动脉瘤的经验.方法 回顾性分析25例颅内AVM合并动脉瘤的临床资料.所有病例均经全脑血管造影(DSA)确诊,按照Redekop分型进行治疗.结果 动脉瘤完全栓塞23例,部分栓塞2例.畸形血管团完全消失7例,消失90％以上9例,消失80％～90％7例,消失80％以下2例.栓塞后手术切除12例,栓塞后伽玛刀治疗6例.所有病人均未出现与血管内治疗相关的并发症.随访25例,时间0.5～3年,无再次出血及死亡.DSA复查18例,其中动脉瘤和畸形血管团均不显影14例,动脉瘤不显影但畸形血管团少许残留4例.结论血管内治疗是颅内AVM合并动脉瘤安全、有效的治疗方法,Redekop分型可对其治疗提供指导.     

Relationships between hemorrhage, angioarchitectural factors and collagen of arteriovenous malformations

Objective While associations between the angioarchitecture of arteriovenous malformations (AVMs) in the brain and pathological features have been described, here we investigated the relationship between the angioarchitecture, the pathological features of the vessel wall, and hemorrhagic events. Methods The study was conducted on 43 patients: 16 with ruptured AVM (rAVM), 15 with non-ruptured AVM (nrAVM), 6 with craniocerebral trauma (control) and 6 with epilepsy (control). The diagnosis of AVM was confirmed by preoperative digital subtraction angiography. Tissues were stained with hematoxylin and eosin and Masson’s trichrome (for collagen fibers) to evaluate the vessel wall structure and endothelial integrity. The content and distribution of collagen types I and III in the vessel wall were assessed by immunohistochemical staining. Results In the nrAVM group, the nidus had more draining veins than the rAVM group (P <0.05). Severely damaged endothelial cells, significantly fewer smooth muscle cells in the media, and hyperplasic type-I and -III collagen fibers were found in the rAVM group. The content of collagen types I and III in rAVMs was higher than that in the nrAVM (P <0.05) and control groups (P <0.01). Conclusion There is an association between angioarchitectural features such as the number of draining veins and the pathological structure of the AVM wall. These abnormalities may contribute to AVM rupture.     

荧光造影和B超在脑浅表动静脉畸形手术中的联合应用

目的 探讨B超和吲哚菁绿血管造影(ICGA)在脑浅表动静脉畸形(AVMs)手术中的应用价值.方法 回顾性分析自2009年1月至12月北京天坛医院神经外科血管组联合应用B超和ICGA辅助切除的16例脑浅表AVMs患者临床资料,同时分析2种术中辅助技术对AVMs定位、边界确定及血管类型鉴别的作用.结果 术中联合应用ICGA和B超能有效帮助定位AVMs,确定其边界,帮助辨认供血动脉和引流静脉.16例脑浅表AVMs患者共行开颅手术16次,均全切病灶,手术后经DSA证实AVMs无残留.结论 脑浅表AVMs手术中联合应用ICGA和B超能有效帮助准确切除病灶,判断有无畸形残留,具有较高的临床应用价值.

Abstract：

Objective To evaluate the surgical effect of intraoperative combined use of B-ultrasound and indocyanine green angiography (ICGA) in the surgery of superficial cerebral arteriovenous malformations (AVMs). Methods Sixteen patients with superficial cerebral AVMs,admitted to our hospital from January 2009 to December 2009, were performed surgery with the help of intraoperative B-ultrasound and ICGA; the clinical data of these patients were retrospectively collected.The ability of intraoperative B-ultrasound and ICGA in distinguishing AVMs' vessels (draining veins,feeding and nidal arteries) from each other and from normal vessel was both evaluated.Results The combination of B-ultrasound and ICGA allowed accurate and real-time localization of the AVMs' nidus,helped to define the boundary and identify the draining veins and feeding arteries. Total lesion removal was achieved by 16 successful surgeries in 16 patients, which was confirmed by postoperative DSA.Conclusion The combination of B-ultrasound and ICGA in the surgery of superficial cerebral arteriovenous malformations allows accurate and real-time localization of the AVMs' indus and helps to assess the completeness of lesion removal, indicating its value in the surgery of superficial cerebral AVMs.     

西藏高原地区血管内介入治疗破裂颅内动脉瘤

目的 探讨西藏高原地区经血管内介入治疗破裂出血的颅内动脉瘤的安全性、有效性及可行性.方法 回顾性分析2010年1月至2010年11月我院经血管内介入治疗的8例破裂出血的颅内动脉瘤.8例患者均行DSA检查确诊,并根据动脉瘤的特点实施个性化血管内介入治疗:5例行弹簧圈栓塞术,2例行支架辅助弹簧圈栓塞术,1例行单纯支架贴敷术.结果 8例中完全栓塞6例,次全栓塞1例,单纯支架贴敷1例.术中复查DSA显示:动脉瘤显影消失7例,单纯支架置入后瘤腔内对比剂滞留1例.1例宽颈动脉瘤行支架辅助弹簧圈栓塞术后出现对侧肢体偏瘫(肌力0级),经给予加强抗凝、抗血小板聚集、改善微循环等治疗后,下肢肌力恢复至Ⅴ级,上至肌力恢复至接近Ⅴ级.除术前Hunt-Hess分级Ⅳ级、GCS评分4分的1例因继发严重脑积水恢复至Hunt-Hess分级Ⅲ级、GCS评分7分外,其余7例均恢复正常.门诊随访1-5个月,无再出血或缺血事件发生.结论 高原地区经血管内介入治疗破裂出血的颅内动脉瘤是安全、有效的,但围手术期的处理具有高原特色.

Abstract：

Objective To evaluate the safety, efficacy and feasibility of endovascular interventional therapeutic techniques for ruptured hemorrhagic intracranial aneurysms in highland in Tibet. Methods Retrospectively analyzed the therapeutic effects of endovascular interventional treatment for ruptured hemorrhagic intracranial aneurysms in 8 cases in highland in Tibet 8 cases were performed DSA for accurate diagnosis and individualized endovascular interventional treatment were undergone according to the feature of the aneurysms; coiling in 5 cases, coiling with assistance of stent in 2 and pure stenting in 1. Results Among the 8 cases complete embolization was gained in 6 and hypo - complete embolization in 1. DSA review during procedure showed the image of aneurysm disappeared in 7 cases and retention of contrast agent inside the aneurysm in the case which was purely stented. Contralateral hemiplegia of limbs which muscle strength was 0 grade occurred in 1 case with wide - necked aneurysm treated by coiling with stent assistance after procedure. After the intensive treatment of antiplatelet, anticoagulation and to improve microcirculation, the muscle strength recovered to Ⅴ grade in the lower limb and near Ⅴ grade in the upper limb. After procedure except 1 case whose Hunt & Hess grade was in Ⅵ and GCS was 4 improved Hunt & Hess grade to Ⅲ and GCS to 4 because of secondary severe hydrocephalus, the other cases were all well recovered. During 1 to 5 months following - up of outpatient no re - hemorrhagic or ischemic event occurred. Conclusions Endovascular interventional treatment is safe, mini- invasive, effective and feasible for ruptured hemorrhagic intracranial aneurysms in highland in Tibet, but the peri - operative management was highland characteristic.     

Concurrent arterial aneurysms in brain arteriovenous malformations with haemorrhagic presentation

OBJECTIVE: To assess the effect of concurrent arterial aneurysms on the risk of incident haemorrhage from brain arteriovenous malformations (AVMs). METHODS: In a cross sectional study, 463 consecutive, prospectively enrolled patients from the Columbia AVM Databank were analysed. Concurrent arterial aneurysms on brain angiography were classified as feeding artery aneurysms, intranidal aneurysms, and aneurysms unrelated to blood flow to the AVM. Clinical presentation (diagnostic event) was categorised as intracranial haemorrhage proved by imaging or non-haemorrhagic presentation. Univariate and multivariate statistical models were applied to test the effect of age, sex, AVM size, venous drainage pattern, and the three types of aneurysms on the risk of AVM haemorrhage at initial presentation. RESULTS: Arterial aneurysms were found in 117 (25%) patients with AVM (54 had feeding artery aneurysms, 21 had intranidal aneurysms, 18 had unrelated aneurysms, and 24 had more than one aneurysm type). Intracranial haemorrhage was the presenting symptom in 204 (44%) patients with AVM. In the univariate model, the relative risk for haemorrhagic AVM presentation was 2.28 (95% confidence interval (CI) 1.12 to 4.64) for patients with intranidal aneurysms and 1.88 (95% CI 1.14 to 3.08) for those with feeding artery aneurysms. In the multivariate model an independent effect of feeding artery aneurysms (odds ratio 2.11, 95% CI 1.18 to 3.78) on haemorrhagic AVM presentation was found. No significant effect was seen for intranidal and unrelated aneurysms. The attributable risk of feeding artery aneurysms for incident haemorrhage in patients with AVM was 6% (95% CI 1% to 11%). CONCLUSIONS: The findings suggest that feeding artery aneurysms are an independent determinant for increased risk of incident AVM haemorrhage.     

三维CT血管造影在脑动静脉畸形诊治中的初步应用经验

目的 评估三维CT血管造影（3D－CTA）在脑动静脉畸形诊断及术前评估中的应用。方法 对我科收治的25例脑动静脉畸形患者采用3D－CTA检查，并同期行脑数字减影血管造影（DSA），比较两种检查的结果。结果 3D－CAT显示了24例动静脉畸形，3D－CTA在显示畸形血管闭、供血动脉和引流静脉的三维构造以及空间关系上优于DSA，并能显示三者与颅骨的关系。3D－CTA虽未能发现1例小型小脑动静脉畸形，但其显示了一个位于小脑后下动脉（PICA）远端的供血动脉动脉瘤，并确定了出血系动脉瘤而非动静脉畸形。3D－CTA可以模拟手术入路时可观察到的血管构造，有助于正确判断动静脉畸形的各种成分，提高手术的安全性。结论 3D－CTA对脑动静脉畸形的诊断及其术前评估有其独特的价值。尤其适合于大型脑动静脉畸形、动静脉畸形合并动脉瘤以及颅内巨大血肿怀疑系动静脉畸形破裂者。它与DSA可互补，但尚无法取代DSA。     

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     

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。     

Structural features of cerebral arteriovenous malformations according to the data of optic microscopy and scanning electron microscopy of corrosion specimens

The aim of this study was to investigate structure of cerebral arteriovenous malformations (AVM). We examined and treated 5 patients with AVMs of cerebral hemispheres. Treatment consisted of endovascular embolization with subsequent surgical resection of AVM. The series included 3 female and 2 male patients (age 19-44, mean - 28 years). Histoacryl (B. Braun, Germany) was used for embolization. Corrosion specimens were prepared according to standard technique and examined using optic and scanning electron microscopy. AVMs had similar structure. Casts were formed by distal segments of afferent arteries, fistulas, interjacent venous vessels, proximal segments of draining veins and vessels of angiomatous surrounding. The latter consisted of abnormal network of small arteries, veins, fistulas and dilated capillaries. The most variable length and formation of glomeruli was characteristic for interjacent venous vessels. AVMs extensively anastomosed with cerebral vessels. Big amount of aneurysms and aneurysmatic bulgings was present. Aneurysms of intranidal segment of afferent artery and angiomatous vessels are demonstrated.     

Superior petrosal sinus dural arteriovenous malformation with varix indenting brain stem--report of a case and review of the literature

A rare case of the dural AVM mainly around the left petrosal sinus was reported. A 64 years old man was admitted just after the sudden onset of severe headache and nausea. The CT scan revealed subarachnoid hemorrhage in the left ambient cisterns. A small hematoma was also found in the left cerebellar peduncle. External carotid angiogram showed a dural AVM which nidus was located adjacent to the left superior petrosal sinus. Its feeding arteries were as follows; the middle meningeal artery, the artery of foramen rotundum, the accessory meningeal artery, the dural branch of occipital artery and the ascending pharyngeal artery. The voluminous petrosal vein and the dilated cortical veins were identified as drainers and, the portion of the latter appeared as "varix" embedded in the pons, which was clearly delineated by MRI. In the venous phase, stenotic straight sinus and residual Falcine sinus were illustrated. Superselective embolization of the feeding arteries was employed followed by the direct clippings of draining vein. Postoperative course was uneventful. The present case should be classified into the tentorial dural AVM. Only 26 cases of this rarely encountered entity was reported in the literature. Based on both the present and the previously reported cases, the clinical features, treatment and pathogenesis of this disease were briefly discussed.     

术中彩色多普勒结合荧光造影在脑动静脉畸形手术中的应用

目的探讨术中彩色多普勒结合吲哚菁绿血管造影在脑动静脉畸形（cAVM）手术的应用价值。方法回顾性分析46例cAVM的临床资料。手术切除cAVM过程中,使用彩色多普勒探查以确定畸形血管团位置和供血动脉来源,并与术前CTA对比。同时使用吲哚菁绿进行术中荧光造影,观察畸形血管团血流方向,以辨认浅表供血动脉及引流静脉。手术切除畸形血管后再行多普勒及荧光造影检查以评估手术效果。结果 46例病人术中彩色多普勒所示病变定位与术前CTA一致,术中彩色多普勒对深部供血动脉分辨良好,但8例（17.4%）病变血管在彩色多普勒下难以发现。荧光造影对浅表血管血液流向分辨清晰,手术切除畸形血管团完全。术后病人出现轻度神经功能损害6例,经术后康复锻炼后无明显后遗症,其他病人神经功能保留良好。结论术中彩色多普勒结合吲哚菁绿荧光造影对cAVM术中定位、供血动脉及引流静脉有良好的实时判断价值,有助于确定手术切除方案,准确切断供血动脉,减少术中出血及手术副损伤,降低术后畸形血管团残留率。     

影像后处理技术在颅内动静脉畸形治疗中的应用价值

目的探讨基于影像融合和三维表面重建影像后处理技术的术前模拟在颅内动静脉畸形(AVM)治疗中的应用价值。方法回顾性分析2018年1月至2019年12月苏州大学附属第一医院神经外科手术治疗21例AVM患者的临床资料。术前均行头颅CT、3.0 T MRI和三维数字减影血管造影(3D-DSA)检查,利用iPlan软件将所有影像学数据配准融合并重建出三维模型,根据模型评估AVM的位置、范围、与功能区的关系以及供血动脉、引流静脉的位置,然后与术中所见进行比对,并在显微镜下切除AVM。术后行头颅MRI和DSA随访,同时检测患者的四肢活动、语言功能及视力情况。结果21例患者均顺利完成术前模型的重建,其中20例利用模型在术中成功辨认AVM、功能区、供血动脉及引流静脉的位置;1例因术野内无明显粗大的血管且脑内血肿造成脑沟受压,脑沟回形态不清晰,无法完成比对。术前模型与术中评估的符合率为95.2%(20/21)。21例患者中,AVM全切除20例,次全切除1例。5例因出血导致肢体活动障碍的患者中,4例于术后3个月内恢复正常;1例因出血导致偏盲的患者,术后3个月复查视野缺损有所改善。1例因术后再出血,出现肢体活动障碍,于2周后恢复正常。21例患者的随访时间为(15.8±6.7)个月(3~25个月),行影像学复查均未发现再出血。4例癫痫起病的患者中有3例术后无发作,1例于术后3个月内仍有发作,经调整抗癫痫药物治疗后发作停止。结论利用影像后处理技术有助于在术前对AVM的位置、范围、与功能区的关系以及供血动脉、引流静脉的位置作出准确评估,可提高AVM的全切除率,减少术后并发症的发生。