脑动静脉畸形立体定向放射外科治疗的新思维

动静脉畸形(AVM)是立体定向放射外科治疗技术的主要适应证之一，经随访疗效确切。近年来，为提高脑动静脉畸形立体定向放射外科的治疗效果，在治疗方法、疗效评价和并发症的防治等方面有许多新的发展.     

立体定向放射外科治疗颅内动静脉畸形研究进展

近年来对立体定向放射外科治疗颅内动静脉畸形的临床疗效、并发症及其影响因素 ,放射治疗后的影像学和病理学变化等方面进行了较深入的临床研究并取得了新的进展。     

立体定向放射外科治疗颅内动静脉畸形研究进展

近年来对立体定向放射外科治疗颅内动静脉畸形的临床疗效,并发症及其影响因素,放射治疗后的影像学和病理学变化等方面进行了较深入的临床研究并取得了新的进展。     

立体定向放射外科治疗脑动静脉畸形

脑动静脉畸形(AVMs)常见于青少年,主要临床症状有癫痫、出血、头痛和进展性中枢神经损害。目前外科治疗 AVMs 除手术切除和导管栓塞外,立体定向放射外科方法日益受到各国医学界重视,越来越多的 AVMs 病人接受该方法治疗。现收集近年有关文献,对此方法加以介绍。     

立体定向放射外科治疗硬脑膜动静脉瘘

目的评估立体定向放射外科治疗硬脑膜动静脉瘘的安全性和有效性。方法采用伽玛刀治疗硬脑膜动静脉瘘16例，其中单纯伽玛刀治疗7例，经动脉途径栓塞或手术治疗后再行伽玛刀治疗9例。根据Congard分型，硬脑膜动静脉瘘Ⅰ型4例，Ⅱa型5例，Ⅱa b型3例，Ⅲ型3例，Ⅳ型1例。靶点边缘剂量16～20Gy，平均18Gy，靶点边缘被50％～70％等剂量曲线所包含。所有患者均获得随访，随访时间为5～108个月。结果14例患者术后症状消失，2例部分改善。12例MRI或造影证实瘘口完全或近全闭塞，4例部分闭塞。无放射治疗导致的并发症。结论立体定向放射外科是一种治疗硬脑膜动静脉瘘安全、有效的方法。对侵袭型硬脑膜动静脉瘘且伴有广泛皮质静脉引流的患者，血管内治疗或手术治疗结合放射外科是一种有效的治疗模式。     

旋转式伽玛刀治疗脑动静脉畸形254例

目的 评估旋转式伽玛刀对脑动静脉畸形(AVM)的治疗效果及术后并发症。方法 1996～2002年应用旋转式伽玛刀治疗脑AVM患者254例。AVM平均直径24mm，周边剂量平均17.7Gy，中心剂量平均35．6Gy。结果平均随访38．4个月(12～72个月)。9例患者(4．0％)伽玛刀治疗后5～21个月发生畸形血管破裂出血或再出血。225例患者治疗后行CT或MR检查，68例(30．2％)出现放射性水肿，其中6例(2．7％)遗留永久并发症。184例治疗后行脑血管造影或磁共振血管成像检查，治疗后1、2和3年的血管闭塞率分别为38．8％，71．2％和74．3％。结论旋转式伽玛刀是一种新的可靠的立体定向治疗设备，对AVM治疗后2—3年畸形血管完全闭塞率达70%以上，治疗后并发症少，且很少出现永久性并发症。     

立体定向放射外科治疗脑动静脉畸形的效果观察

目的分析立体定向放射外科治疗脑动静脉畸形的临床疗效和并发症发生情况。方法选取2007-07-30—2012-07-30我院脑外科收治的经磁共振(荷兰Philips 1.5T核磁共振)及数字减影血管造影(万东CGO-2100C,DSA)检查诊断为脑动静脉畸形的患者63例,均采用立体定向放射外科进行治疗。治疗结束后对所有患者随访2~3年,评价立体定向放射外科治疗的临床效果。结果经立体定向放射外科治疗后,33例(53.4%)患者完全闭塞;23例(36.5%)患者部分缩小;7例(11.1%)患者不变。术后,2例(3.2%)患者发生再出血,2例(3.2%)患者轻度水肿。结论立体定向放射外科治疗动静脉畸形临床效果令人满意,定位准确,创伤小且远期并发症相对较轻,患者容易接受,对于多支供血、广泛的动静脉畸形,联合介入栓塞治疗有效率高,尤其对于位置较深或位于脑重要结构的动静脉畸形而言,立体定向放射外科是最合适的选择。     

放射外科治疗能降低脑动静脉畸形出血的风险

血管造影显示，立体定向放射外科治疗可消除大多数潜伏数年的脑动静脉畸形。但是，这种方法对出血风险的影响还不太清楚。     

血管内栓塞结合二期立体定向放射外科治疗颅内动静脉畸形的效果

目的探讨血管内介入栓塞结合二期立体定向放射外科(SRS)治疗颅内动静脉畸形(AVM)的安全性及有效性。方法回顾性分析2010年1月至2012年12月第二军医大学附属长海医院神经外科介入栓塞结合二期SRS综合治疗AVM并获得影像学随访患者66例的临床资料,随访时间为7~96个月。将DSA显示血管流空影完全消失视为治愈。按照是否治愈分为治愈组29例,未治愈组37例,观察两组AVM是否破裂、栓塞前体积大小和栓塞程度等不同因素对综合疗法治疗AVM治愈率的影响,并采用Logistic回归分析影响综合疗法治愈率的因素。结果 (1)治愈组中,AVM破裂22例(75.9%),未破裂7例(24.1%),直径3 cm和≥3 cm分别为26例(89.7%)和3例(10.3%),患者Spetzler-Martin(SM)分级Ⅰ~Ⅲ级;未治愈组中,AVM破裂20例(54.1%),未破裂为17例(45.9%),直径3 cm和≥3 cm分别为18例(48.6%)和19例(51.4%),34例患者(91.9%)SM分级Ⅰ~Ⅲ级。(2)随访过程中,29例(43.9%)达到影像学治愈,64例(97.0%)改良Rankin量表(mRS)评分为0~1分;发生并发症6例。(3)Logistic多因素分析显示,AVM大小(OR=0.141,95%CI:0.035~0.570,P0.01)和介入栓塞程度(OR=2.414,95%CI:1.038~5.613,P0.05)是治愈率的影响因素。结论血管介入栓塞联合SRS治疗颅内AVM是有效且安全的。AVM直径3 mm是综合疗法治愈率的独立保护因素,介入栓塞程度是未达到影像学治愈综合疗法治愈率的危险因素。     

脑动静脉畸形的发病机制

脑动静脉畸形是一种常见的脑血管病,其确切发病机制仍不清楚,目前认为是多种因素所引起,包括先天因素和后天因素。     

Role of Embolization for Cerebral Arteriovenous Malformations

Cerebral arteriovenous malformations (AVMs) are complex high-flow lesions that can result in devastating neurological injury when they hemorrhage. Embolization is a critical component in the management of many patients with cerebral AVMs. Embolization may be used as an independent curative therapy or more commonly in an adjuvant fashion prior to either micro- or radiosurgery. Although the treatment-related morbidity and mortality for AVMs—including that due to microsurgery, embolization, and radiosurgery—can be substantial, its natural history offers little solace. Fortunately, care by a multidisciplinary team experienced in the comprehensive management of AVMs can offer excellent results in most cases.     

Onyx栓塞治疗脑动静脉畸形11例临床分析

目的：介绍应用Onyx栓塞治疗脑动静脉畸形的体会。方法：采用Onyx-18栓塞治疗11例脑动静脉畸形。结果：11例中,畸形血管团栓塞80%以上2例,栓塞50%～80%7例,栓塞50%以下2例;并发脑室出血1例,无一例死亡和黏管。结论：Onyx是治疗脑动静脉畸形较为理想的栓塞材料,但需注意掌握栓塞技巧,减少并发症的发生。     

影响脑动静脉畸形手术效果的临床因素

脑动静脉畸形(AVM)是常见的脑血管畸形。目前公认AVM切除术是AVM外科治疗中最为理想的 方法,是否采取手术治疗主要取决于手术所引起的死亡和严重病残率是否低于AVM的自然史。     

巨大脑动静脉畸形

巨大脑动静脉畸形（AVM）指最大直径〉6cm、具有高流量特征的一类特殊脑动静脉畸形（AVM）。大多数巨大AVM患者Spetzler-Martin分级为Ⅳ～Ⅴ级。巨大AVM是一类较为少见的AVM，致残率和病死率极高。对巨大AVM的治疗仍是神经外科面临的一个挑战。文章对巨大AVM的自然史、血流动力学特征和治疗做了综述。     

低场强MR对脑动静脉畸形的诊断价值

目的　评价低场强MR对脑动静脉畸形的诊断价值。方法　回顾2 2例经低场强MRI检查,并通过数字减影血管造影(DSA)证实(5例为进一步手术病理证实)的脑动静脉畸形(AVM)病例,分析其MRI表现。结果　低场强MRI检查中,异常的血液流空征象为直接征象,脑内及蛛网膜下腔出血,脑组织萎缩、铁环征等均为间接征象。结论　低场强MRI对AVM有定性定位诊断价值。     

Long-term outcomes of 170 brain arteriovenous malformations treated by frameless image-guided robotic stereotactic radiosurgery: Ramathibodi hospital experience

This study was conducted to report long-term outcomes of the frameless robotic stereotactic radiosurgery (SRS) for brain arteriovenous malformation (AVM) at Ramathibodi Hospital.Retrospective data of patients with brain AVM (bAVM), who underwent CyberKnife SRS (CKSRS) at Ramathibodi Hospital from 2009 to 2014, were examined. Exclusion criteria were insufficient follow-up time (<36 months) or incomplete information. Patients’ demographics, clinical presentation, treatment parameters, and results were analyzed. Excellent outcome was defined as AVM obliteration without a new neurological deficit. Risk factors for achieving excellent outcome were assessed.From a total of 277 CKSRS treatments for bAVM during the 6 years, 170 AVMs in 166 patients met the inclusion criteria. One hundred and thirty-nine cases (81.76%) presented with hemorrhages from ruptured bAVMs. Almost two-thirds underwent embolization before radiosurgery. With the median AVM volume of 4.17 mL, three-quarters of the cohort had single-fraction CKSRS, utilizing the median prescribed dose of 15 Gray (Gy). In the multisession group (25.29%), the median prescribed dose and the AVM volume were 27.5 Gy and 22.3 mL, respectively. An overall excellent outcome, at a median follow-up period of 72.45 months, was observed in 99 cases (58.24%). Seven AVMs (4.12%) ruptured after CKSRS but 1 patient suffered a new neurological deficit. Two patients (1.18%) were classified into the poor outcome category but there were no deaths. Negative factors for excellent outcome, by multivariate regression analysis, were the male sex and multisession SRS delivery, but not age, history of AVM rupture, previous embolization, or AVM volume.Despite relatively larger bAVM and utilizing a lower prescribed radiation dose, the excellent outcome was within the reported range from previous literature. This study offers one of the longest follow-ups and the largest cohorts from the frameless image-guided robotic SRS community.     

Stereotactic radiosurgery for treatment of Cushing disease: an Australian experience

Stereotactic radiation therapy has emerged as an alternative to conventional radiotherapy for treatment of Cushing disease. The aim of this study was to investigate the efficacy and safety of this treatment. Records of patients with Cushing disease treated with stereotactic radiation were reviewed. Seventeen patients underwent stereotactic radiosurgery. Ten achieved remission after a mean of 23 (95% confidence interval, 15–31) months, and two developed hormone deficiencies.     

立体定向抽吸引流术治疗大面积脑叶出血和脑疝

43岁男性,诊断为占位性左侧枕叶出血,血肿破入整个脑室系统.入院时处于深昏迷状态,有脑疝的临床体征,Glasgow昏迷量表评分4分.由于患者年龄较轻且无高血压史,因此高度怀疑存在血管畸形.鉴于患者存在生命危险,医生建议将开颅和血肿清除术作为首选治疗方案,但被其家属以非医疗原因拒绝.为挽救患者的生命,决定行立体定向抽吸术,并得到患者家属认可.在操作过程中和操作后5 d内应用了大剂量尿激酶(50000 IU)治疗.1个月后,该患者转归良好,Glasgow转归量表评分为5分.