CTA指导下脑动静脉畸形出血的显微手术治疗

目的探讨头颅CT血管造影（CTA）在脑动静脉畸形（AVM）出血患者显微手术中的作用。方法 2010年6月至2013年6月收治41例脑AVM出血患者,均行头颅CT、3D-CTA明确诊断,全部病例均于一期行显微手术。结果本组41例AVM出血后显微手术治疗均获得了成功,所有患者均一次性全部切除畸形血管团,效果满意。患者术后随访2月~3年,无死亡患者,无再次出血患者,未发生灌注压突破综合征。按日常生活能力（ADL）分级评价患者预后,ADLⅠ级36例,Ⅱ级5例。结论对颅内出血怀疑AVM出血者,尽快行头颅3D-CTA明确诊断,急诊一期手术治疗效果良好。     

脑动静脉畸形手术治疗与血管内栓塞治疗

目的通过对81例脑动静脉畸形(AVM)患者分别进行直接手术切除和血管内栓塞治疗的总结,探讨AVM治疗手段的可行性和有效性。方法(1)直接手术23例,均为AVM合并脑内血肿而行急诊开颅血肿清除术 AVM切除术。(2)58例行血管内超选择栓塞术(NBCA胶),栓塞前行二维或三维DSA检查。结果直接手术组,术后复查头部MRI或DSA示病灶全切除12例,部分切除6例并在术后联合血管内栓塞达到痊愈,治愈率52.2%,病残率26.1%,死亡率21.7%。血管内栓塞组,以最后一期栓塞后的DSA资料统计栓塞程度,有49例达到完全栓塞,8例畸形血管团减少50%以上,1例减少50%以下。结论对脑AVM破裂出血且危及生命的应行急诊开颅血肿清除术并尽可能切除畸形血管团。小型AVM、单支供血AVM或Spetzler-Martin分级Ⅲ级以下的病例,追求一期完全栓塞是有可能的;Ⅲ级以上的脑AVM,采用分次、分期血管内栓塞可减少并发症和明显改善症状。因此,治疗脑AVM手段的选择应根据患者的具体情况而定。     

脑动静脉畸形大量出血的急诊手术治疗

目的 探讨脑动静脉畸形(AVM)大量出血急诊手术治疗的有效性和安全性.方法 回顾性分析36例AVM大量出血急诊手术治疗的临床资料.结果 本组采用单纯脑内血肿清除者20例,脑内血肿清除同时切除AVM者16例,术后病理证实为AVM.所有病例术后病情稳定后均做全脑血管造影(DSA)检查,结果显示术中已切除AVM者未再发现AVM,未切除者均证实AVM存在.在未切除AVM的病例中,行二期手术切除者8例,血管内栓塞者7例,γ-刀治疗者3例,术后再出血死亡者2例.3个月后随访,恢复良好26例,中残4例,重残3例,植物生存1例.结论 脑动静脉畸形大量出血采用急诊手术清除脑内血肿是救治成功的关键,为患者生存和后续治疗提供条件,但手术风险较大,术中止血困难和术后再出血是死亡的主要原因.     

儿童脑动静脉畸形出血早期诊断和显微外科治疗

目的 探讨儿童脑动静脉畸形(AVM)破裂出血急性期的诊断方法和显微外科治疗的时机与手术技术.方法 对2002年6月至2011年6月间收治的32例儿童AVM出血患者进行回顾性分析.除CTA和MRA检查外,本组行早期全脑DSA检查24例,另外入院时因出血量大发生脑疝者8例,立即行血肿清除术,其中3例病情稳定后再行DSA检查.明确诊断后根据Spetzler-Martin分级选择治疗方案.24例Spetzler-Martin分级Ⅰ～Ⅲ级AVM患者行急性期(3d内)显微外科治疗,其中栓塞后再手术2例.结果 8例急诊行显微手术血肿清除术者,术后死亡2例,镜下AVM完全切除2例,部分切除1例.病情稳定后行DSA检查证实AVM者3例,继而再行显微手术切除.24例急性期显微手术AVM切除者,术中显微镜下AVM血管团和颅内血肿完全清除.术后获DSA或CTA复查18例,均未见病灶残留.随访3-12个月.根据GOS评定:24例Sptetzler-Martin分级Ⅰ～Ⅲ级AVM患者恢复良好者21例,轻残2例,重残1例,无死亡病例.结论 DSA是儿童AVM出血早期诊断主要的检查手段.急性期显微手术可降低出血病死率和改善预后.     

脑血管畸形急性出血并脑内血肿的手术治疗

目的 探讨脑动静脉畸形(AVM) 出血并颅内血肿形成的急诊手术问题.方法 37例CT示颅内血肿,怀疑AVM 出血,32例急诊手术前经MRA检查提示脑AVM21例,其中29例行血肿清除加AVM显微切除术,8例行单纯血肿清除术,10例行去骨瓣减压术.结果 死亡4例,存活33例中恢复优良21例,良7例,差5例. 29例术后复查DSA或MRA,20例AVM消失.结论 急诊显微外科手术治疗是AVM破裂出血首选治疗方法,能够提高脑AVM破裂出血的治愈率,降低致残率.MRA适合急诊术前检查,可快捷、安全显示AVM及主要供血动脉,指导制定手术方案.     

脑动静脉畸形破裂出血并脑疝的急诊手术治疗

目的 总结急诊手术治疗脑动静脉畸形(AVM)破裂出血并脑疝的手术经验.方法 回顾性分析23例AVM破裂出血并脑疝病人的临床资料,均行急诊手术治疗,其中行血肿清除加AVM全切除15例(65.2%),行血肿清除加AVM部分切除8例(34.8%).结果 本组术后无再出血.复查MRA 15例,发现AVM残存8例.随访6个月,按GOS预后评分:5分(恢复良好)14例,4分(轻度残疾)4例,3分(重度残疾)2例,2分(植物生存)2例,1分(死亡)1例.结论 AVM破裂出血并脑疝应尽快行急诊手术去骨瓣减压、血肿清除,并根据术中情况行AVM全切除或部分切除,可有效降低病死率和病残率.     

脑动静脉畸形破裂出血急诊手术治疗

目的探讨脑动静脉畸形（AVM）破裂出血的术前诊断、急诊手术治疗及疗效。方法回顾性分析2008～2011年急诊开颅手术治疗17例NAVM出血患者临床资料。结果手术中判断病灶Spetzler分级：I级2例,Ⅱ级4例,Ⅲ级6例,IVY3例,V级2例。14例清除血肿同时切除病灶;术后新发癫痫4例,药物控制良好。术后随访6月～3年,10例预后良好,4例中残,3例重残。结论掌握脑AVM破裂出血的手术策略和显微外科技巧,若手术中条件允许,清除血肿同时切除病灶预后较好。     

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.     

CTA在脑动静脉畸形出血急诊显微外科手术治疗中的指导意义

目的 探讨多层螺旋CT血管造影(CTA)存脑动静脉畸形(AVM)出血急诊显微外科手术治疗中的指导意义. 方法 同顾性分析四川省人民医院神经外科自2004年8月至2007年10月应用CTA指导急诊显微外科手术治疗脑AVM出血的21例患者的临床资料. 结果 本组21例脑AVM患者均行血肿清除及脑AVM的显微外科手术治疗,畸形血管伞切15例.部分切除5例,1例延髓血管畸形未能切除.痊愈6例(皮层下非功能区血肿5例,小脑血管畸形1例),好转14例(皮层下功能区血肿7例,小脑血肿4例,基底节区血管畸形3例),死亡1例(延髓血管畸形).结论 CTA可完成脑AVM的诊断,指导脑AVM出血的急诊显微外科手术治疗.     

出血性动静脉畸形的显微外科治疗体会

目的总结急性出血性脑动静脉畸形(AVM)的诊断及急诊显微手术治疗经验。方法对2007年7月至2015年6月收治的19例经CT血管造影和(或)病理检查证实为脑AVM患者的资料进行回顾性分析。结果按GOS评分,恢复良好15例,轻残1例,重残1例,死亡2例。结论颅内AVM破裂出血形成血肿急诊显微手术开颅清除血肿并AVM切除术能够有效提高抢救成功率,降低伤残率和死亡率。     

立体定向伽玛刀治疗脑动静脉畸型研究

目的评估伽玛刀(γ-刀)立体定向放射手术治疗脑动静脉畸形(AVM)的疗效;探讨脑AVM的γ-刀治疗定位方法。方法用立体定向Leksellγ-刀放射外科治疗系统对216例脑AVM进行γ-刀立体定向放射手术,并随访17～31个月。男性患者162例,女性54例,年龄1.5～83岁(Md=26),Spetzler Martin分级:I级42例,Ⅱ级68例,Ⅲ级95例,Ⅳ级7例及Ⅴ级4例。AVM体积0.3～43.9cm3(Md=7.1),放射手术周边剂量12～30Gy,平均(21.2±6.4)Gy。用1.5Tesla磁共振行磁共振血管造影(MRA)定位156例,数字减影血管造影(DSA)定位22例,MRA与DSA联合定位38例。结果γ-刀治疗后的AVM闭塞情况和并发症的发生与其体积、分级、定位方法、周边剂量、剂量规划及质量控制等因素有关。对体积≤5.0cm3或Spetzler Martin分级<Ⅲ级及周边剂量≥20Gy者,其2年闭塞率超过78.5%。本组有4例γ-刀放射手术后出血,9例并发有明显症状的放射性脑水肿。结论γ-刀高科技手术是治疗脑AVM的一种安全、有效的方法,特别是Spetzler MartinI-Ⅱ级或体积≤5.0cm3的AVM及周边剂量≥20Gy者疗效较好;DSA结合MRA联合定位对提高AVM的闭塞率、降低并发症有帮助。     

对比吲哚菁绿荧光血管造影与数字减影血管造影在脑动静脉畸形手术中的应用(英文)

BACKGROUND The potential utility of intraoperative microscope-integrated indocyanine green( ICG) fluorescence angiography in the surgery of brain arteriovenous malformations( AVMs) and evaluation of the completeness of resection is debatable.Postoperative catheter angiography is considered the gold standard. We evaluated the value of ICG and intraoperative catheter angiography in this setting. METHODS Between January 2009 and July 2013,37 patients with brain AVMs underwent surgical resection of their vascularlesions. ICG videoangiography and an intraoperative catheter angiography were performed in 32 cases,and a routine postoperative angiogram was performed within 48 h to 2 weeks after surgery. The usefulness of ICG findings and the ability to confirm total resection and to identify residual nidus or persistent shunt were assessed and compared to intraoperative and postoperative digital subtraction angiography,respectively. RESULTS There were 7 grade 1,11 grade 2,11 grade 3 and 3 grade 4 Spetzler-Martin classification AVMs. ICG angiography helped to distinguish AVM vessels in 26 patients. In 31 patients,it demonstrated that there was no residual shunting. In one patient,a residual AVM was identified and further resected. Intraoperative catheter angiography detected two additional small residuals that were missed by ICG angiography,both deep in the surgical cavity. Further resection of the AVM was performed,and total resection was confirmed by a repeat intraoperative angiogram. Postoperative angiography in a patient with a grade 4 lesion revealed one additional small deep residual AVM nidus with persistent late shunting missed on both ICG and intraoperative angiography. Overall ICG angiography missed three out of four residual AVMs after initial resection, while the intraoperative angiogram missed one.CONCLUSION Although ICG angiography is a helpful adjunct in the surgery of some brain AVMs,it's yield in detecting residual AVM nidus or shunt is low,especially for deep-seated lesions and higher grade AVMs. ICG angiography should not be used as a sole and / or reliable technique. High-resolution postoperative angiography must be performed in brain AVM surgery and remains the best test to confidently confirm complete AVM resection.     

Intracranial arteriovenous malformations in childhood: presentation, management and outcome.

Cases of true intracranial arteriovenous malformations (AVMs) presenting over a 25 year period were reviewed in order to achieve a better understanding of the behaviour and management of AVMs in children. There were 69 cases, presenting with haemorrhage (78%), seizures (13%) cardiac failure (3%) and focal signs with or without headache (6%). It was less common to present under six years of age. CT scanning, where performed, always demonstrated an abnormality, but this was suggestive of an AVM in less than one third. By contrast, angiography defined the lesion in 82% of initial studies. 59 patients underwent a surgical procedure directed at their AVM or an associated haematoma. Total AVM excision was obtained in 65%, with none of these later rebleeding. Three patients presenting solely with seizures were not operated upon initially, but underwent successful resections of their lesions after later haemorrhages. There were 6 (9%) deaths in the series, with focal deficits in 52% of survivors at last follow up. In the operative group these figures were 3% and 51%, respectively. None of the eight patients operated upon prior to a clinical bleed suffered a new neurological deficit. The role of stereotactic radiosurgery, although not used in any of our cases, is discussed. We believe that our results support an aggressive surgical approach to childhood AVMs, regardless of presentation, given the significant risk of morbidity from a later bleed, and the lack of a clearly better outcome with expectant management or irradiation.     

121例自发性颅内出血的病因和治疗方法探讨

目的:研究自发性颅内出血的病因诊断,并探讨其治疗方法。方法:病例经计算机体层摄影(CT)、磁共振成像(MRI)和腰穿等检查明确诊断及病因。74洲经手术治疗,21例经血管内治疗.9咧经伽玛刀(γ—刀)治疗,17例保守治疗。结果:121例自发性颅内出血中,动脉瘤46例,瞄血管畸形45例,动脉瘤合并血管畸形2例,颅内肿瘤卒中5例,烟雾病2例,21鲕J原因不明。结论:脑动脉瘤和血管畸形是自发性颅内出血最常见的病因(占74.4％),CT和MRI对出血的病因提供诊断线索,脑血管造影能明确病因诊断,根据病因不同、病变大小和部位不同选择合适的治疗方法,大型脑动静脉畸形(AVM)主张联合治疗。     

Surgical strategy for cerebral arteriovenous malformation with acute hemorrhage

BACKGROUND: Presently, there have been craniocerebral operation, interventional embolization, stereotactic radiotherapy and other methods in treating cerebral arteriovenous malformation (AVM). However, the standard of different therapeutic regimens of cerebral AVM at the acute stage of hemorrhage has not been completely identified. OBJECTIVE: To observe the clinical characteristics and therapeutic effects of AVM at the acute stage of hemorrhage in patients, and to analyze corresponding therapeutic strategies. DESIGN: Non-randomized clinical observation. SETTING: Department of Neurosurgery, Foshan First People's Hospital, Sun Yat-sen University. PARTICIPANTS: Forty-six patients with cerebral AVM complicated by hemorrhage admitted to Department of Neurosurgery, Foshan First People's Hospital between January 1999 and December 2006, were involved in this study. All the patients were confirmed as cerebral AVM complicated by hemorrhage by brain angiography or/and postoperational pathology. The involved patients, 32 males and 14 females, averaged 25 years old, ranging from 6 to 62 years. Informed consents of therapeutic items were obtained from the relatives of all the patients. METHODS: ①On admission, skull CT and brain angiography were conducted in the involved subjects. ②The therapeutic method was confirmed according to the consciousness, hematoma region, hematoma volume, imageological results following comprehensive analysis. DSA examination was permitted to identify the size and position of abnormal vessel mass, and the distribution of feeding artery and draining vein. Craniocerebral operation was carried out as early as possible in patients with severe or progressive conscious disturbance, in which most of hematoma with obvious occupied effect or cerebral hernia was located in lobe of brain. The primary thing was to clean intracerebral hematoma for in time decompression. According to different situations, corresponding therapeutic measures were used for resecting abnormal vessel mass, and the treatments of patients were observed. ③The therapeutic effects were assessed following Glasgow outcome scale(GOS) at 3 months after hemorrhage. MAIN OUTCOME MEASURES: ① The examination results of skull CT and brain angiography of patients on admission. ② Treatment of patients. ③ GOS results at 3 months after hemorrhage. RESULTS: Forty-six patients were involved, and all of them participated in the final analysis. ① Examination results of skull CT and brain angiography: Bleeding part: frontal lobe in 7 cases, parietal lobe 15, temporal lobe 19, occipital lobe 3, cerebellar hemisphere 2, and hemorrhage rupturing into ventricle 10. Haematoma volume: small volume of hematoma （< 20 mL）in 4 cases, moderate volume of hematoma （20–50 mL）14 , large volume of hematoma （50–80 mL）21, great volume of hematoma (> 80 mL) 7; Abnormal vessel mass: Among 17 patients undergoing aortocranial angiography, abnormal vessel mass was found in 16 patients, including cortex 13 patients, basal ganglia and thalamencephalon(deep part) 2 patients , and posterior cranial fossa 1 patient. The size of abnormal vessel mass: small (< 3 cm) 4 patients, moderate (3–6 cm) 9 patients, and large (> 6 cm) 3 patients. The type of feeding artery: perforating branch blood-supply 1 patient, cortical branch blood supply 13 patients, mixed branch blood supply 2 patients. The type of draining vein: cortical draining (superficial part) 10 patients, deep part draining 2 patients, and mixed draining 4 patients. ② Treatment condition: Among 17 patients undergoing brain angiography followed by craniocerebral operation, hematoma was removed and AVM was completely resected in 12 patients, hematoma was removed and AVM was partially resected in 3 patients, and only hematoma was resected in 2 patients; Among 24 patients undergoing emergent craniocerebral operation, hematoma was removed and AVM was completely resected in 5 patients, hematoma was removed and AVM was partially resected in 9 patients, and only hematoma was resected in 10 patients; Expectant treatment was carried out in the early stage in 5 patients. When disease condition was stable, AVM resection was separately or complicatedly conducted in 13 patients, embolization in 4 patients, and γ- radiotherapy in 5 patients. ③GOS: 5 patients died in postoperative complications, and among the other patients, 19 had moderate or had not functional impairment, 13 had moderate disability, 6 had severe disability, 2 were vegetative state, and 2 died. ④ Post-operative re-examination of brain angiography: Among 16 patients undergoing AVM, vessel mass disappeared in 9 patients. CONCLUSION: Good therapeutic effects can be obtained by choosing proper therapeutic regimen according to clinical and imageological characteristics of patients with arteriovenous malformation complicated by hemorrhage at the acute stage.     

新型带纤毛弹簧圈栓塞治疗颅内动脉瘤的临床研究

目的 探讨新型带纤毛弹簧罔栓塞治疗颅内动脉瘤的临床疗效. 方法 南方医科大学珠江医院神经外科自2008年3月至9月共收治41例颅内动脉瘤患者(43个动脉瘤),均用新型带纤毛弹簧罔栓塞治疗.回顾性分析患者随访情况,随访时间6～12个月,行脑血管造影或CT脑血管成像或磁共振脑血管成像,了解颅内动脉瘤复发及并发症情况. 结果 41例患者中死亡1例,术后并发脑梗死2例,动眼神经麻痹1例,复发1例,脑积水2例;改良Rankin评分量表评级为0级9例,1级19例,2级7例,3级3例,4级1例,5级和6级各1例. 结论 新型带纤毛弹簧圈栓塞治疗颅内动脉瘤安全有效,对小动脉瘤(<5 mm)有相对优势,对载瘤动脉闭塞有一定优势;但对大脑前动脉、大脑中动脉等较细载瘤动脉,因纤毛的致栓作用可能会造成脑梗死,因此封闭瘤颈时应用此罔要谨慎.     

新型带纤毛弹簧圈栓塞治疗颅内动脉瘤的临床研究

目的 探讨新型带纤毛弹簧罔栓塞治疗颅内动脉瘤的临床疗效. 方法 南方医科大学珠江医院神经外科自2008年3月至9月共收治41例颅内动脉瘤患者(43个动脉瘤),均用新型带纤毛弹簧罔栓塞治疗.回顾性分析患者随访情况,随访时间6～12个月,行脑血管造影或CT脑血管成像或磁共振脑血管成像,了解颅内动脉瘤复发及并发症情况. 结果 41例患者中死亡1例,术后并发脑梗死2例,动眼神经麻痹1例,复发1例,脑积水2例;改良Rankin评分量表评级为0级9例,1级19例,2级7例,3级3例,4级1例,5级和6级各1例. 结论 新型带纤毛弹簧圈栓塞治疗颅内动脉瘤安全有效,对小动脉瘤(<5 mm)有相对优势,对载瘤动脉闭塞有一定优势;但对大脑前动脉、大脑中动脉等较细载瘤动脉,因纤毛的致栓作用可能会造成脑梗死,因此封闭瘤颈时应用此罔要谨慎.     

大型脑动静脉畸形直接显微手术治疗的效果分析

目的通过总结大型脑动静脉畸形的显微手术经验,探讨脑动静脉畸形显微手术的效果以及正常灌注压突破对显微手术的影响。方法回顾性分析93例采用显微外科手术治疗的大型脑动静脉畸形病例,按照Spetzler—Martin分级,3级者37例,4级者35例,5级者21例。结果术后出现再出血及急性脑肿胀者3例（3．2％）,死亡2例。术后对91例患者进行随访,根据GOS分级,恢复良好82例（90．1％）,中残7例（7．7％）,重残2例（2．2％）。结论显微外科手术是治疗大型脑动静脉畸形的有效手段,术前精确的判断及术中精细的操作是手术成功的关键。正常灌注压突破对大型脑动静脉畸形直接显微手术无显著影响。     

新型带纤毛弹簧圈栓塞治疗颅内动脉瘤的临床研究

目的 探讨新型带纤毛弹簧罔栓塞治疗颅内动脉瘤的临床疗效. 方法 南方医科大学珠江医院神经外科自2008年3月至9月共收治41例颅内动脉瘤患者(43个动脉瘤),均用新型带纤毛弹簧罔栓塞治疗.回顾性分析患者随访情况,随访时间6～12个月,行脑血管造影或CT脑血管成像或磁共振脑血管成像,了解颅内动脉瘤复发及并发症情况. 结果 41例患者中死亡1例,术后并发脑梗死2例,动眼神经麻痹1例,复发1例,脑积水2例;改良Rankin评分量表评级为0级9例,1级19例,2级7例,3级3例,4级1例,5级和6级各1例. 结论 新型带纤毛弹簧圈栓塞治疗颅内动脉瘤安全有效,对小动脉瘤(<5 mm)有相对优势,对载瘤动脉闭塞有一定优势;但对大脑前动脉、大脑中动脉等较细载瘤动脉,因纤毛的致栓作用可能会造成脑梗死,因此封闭瘤颈时应用此罔要谨慎.