Onyx胶栓塞治疗颅内动静脉畸形

目的观察采用Onyx胶栓塞治疗颅内动静脉畸形（CAVM）的效果。方法应用Onyx胶栓塞治疗31例CAVM患者,评价治疗效果,并对21例患者术后随访3~18个月。结果 31例CAVM患者中,6例一次性栓塞畸形血管团〉90%,其中畸形血管团完全消失4例,其余2例3个月内DSA复查畸形血管团完全消失;25例一次性栓塞≤90%,均接受多次栓塞或联合放射、手术治疗,其中单纯多次栓塞10例,多次栓塞后放射治疗7例、手术治疗8例。26例栓塞治疗后癫痫、头痛、头晕改善;3例术后出现头痛;2例并发颅内出血,其中1例左小脑动静脉畸形栓塞术后24 h出血,急诊手术治疗无效死亡。结论 Onyx胶用于血管内栓塞治疗CAVM疗效较好,是较为理想的血管内栓塞剂。     

血管内栓塞辅助显微手术治疗复杂难治性脑动静脉畸形

目的　探讨复杂难治性脑动静脉畸形 (AVM)的血管内栓塞辅助显微手术治疗的临床效果。　方法　分析 1999年 11月～ 2 0 0 3年 12月治疗Spetzler分级Ⅲ级以上脑AVM的 3 3例临床资料。Spetzler分级Ⅲ级 2 2例 ,Ⅳ级 9例 ,Ⅴ级 2例。脑AVM体积最大为 7 0cm× 8 6cm× 6 1cm ,最小为 2 5cm× 3 0cm× 2 8cm。所有病例均接受了血管内栓塞辅助显微手术治疗。　结果　 3 3例中 3 1例术后恢复良好 ,其余 2例中度致残。术后行MRI、MRA及DSA检查 ,未见血管流空影像及畸形血管影像。术后 6个月内行DSA血管造影检查证实 3 3例脑AVM完全切除 ,未见畸形血管影像。　结论　Spetzler分级Ⅲ级以上脑AVM是难治性疾病。血管内栓塞辅助显微手术切除可以取得良好的临床疗效。     

大型脑动静脉畸形的显微外科手术治疗

目的：探讨并总结大型脑动静脉畸形（AVM）的显微外科手术治疗策略及手术要点。方法回顾性分析71例大型 AVM病例,按照 Spetzler-Martin 分级,3级者31例,4级者25例,5级者15例,均采用显微手术治疗,其中30例有高出血风险者行术前血管内栓塞。65例全切,6例少量残留,2例残余动静脉畸形外院行伽玛刀治疗。出院行格拉斯哥预后评分（GOS）评价预后。结果1例术前持续昏迷术后轻度改善,余病例主要并发症有偏盲、轻度失语、肌力下降及癫痫等,术后均得到较好恢复。无长期昏迷及死亡病例。术后随访 GOS,恢复良好61例（85．9％）,中残8例（11．2％）,重残2例（2．8％）。结论大型 AVM治疗风险较高,显微外科手术是治疗 AVM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,术前血管内栓塞为 AVM的治疗提供了新思路。     

脑动静脉畸形栓塞术后颅内出血影响因素的多元回归分析

目的分析脑动静脉畸形栓塞术后颅内出血的相关影响因素。方法选取315例脑动静脉畸形患者(c AVM)作为研究对象,运用多元回归分析对患者的性别、年龄、出血史、栓塞体积、高血压病史等脑动静脉畸形出血的多种影响因素进行分析。结果单次栓塞体积≥36.5%的OR=2.184,95%CI为1.117~4.269,(P=0.022,0.05),既往高血压病史的OR=2.184,95%CI为1.041~4.581,(P=0.039,0.05),二者是脑动静脉畸形栓塞术后颅内出血的主要危险因素。结论血管介入治疗脑动静脉畸形最严重的并发症是脑动静脉畸形,单次栓塞体积≥36.5%和既往高血压病史可增加脑动静脉畸形栓塞术后颅内出血的危险性。     

介入栓塞治疗脑动静脉畸形

目的探讨Onyx胶主导栓塞脑动静脉畸形(arteriovenous malformation,AVM)的疗效。方法 2015年9月～2017年10月我科应用Onyx胶栓塞84例AVM,其中Speztler-Martin(S-M)分级Ⅰ级10例,Ⅱ级32例,Ⅲ级22例,Ⅳ级18例,Ⅴ级2例。单纯Onyx胶栓塞67例,联合Glubran胶和(或)弹簧圈栓塞17例。结果 S-MⅠ级完全栓塞治愈率60. 0%(6/10),Ⅱ～Ⅲ级33. 3%(18/54),Ⅳ～Ⅴ级25. 0%(5/20),完全栓塞率34. 5%(29/84)。术中微导管断管、留置各1例,术中出血1例,术后出血4例((3例保守治疗成功,1例死亡),无新发神经功能障碍,并发症发生率8. 3%(7/84)。83例随访3～30个月,中位随访时间7. 5月,再次出血4例,其中死亡1例;完全栓塞的29例无一例复发或再生;栓塞导致出血的5例除1例死亡外,其余均恢复良好。结论 Onyx胶联合不同栓塞材料个体化治疗脑AVM,可以获得较为满意的效果。     

躯虹管

彩色多普勒超声辅助全切除颅内动静脉畸形的临床观察；双侧后交通动脉瘤显微手术治疗；弹簧圈血管内栓塞动脉瘤效果及安全性观察；立体定向血肿排空配伍尿激酶治疗高血压脑出血37例；动脉瘤破裂出血并发慢性脑积水28例诊治报告     

颜面部动静脉畸形的介入治疗

目的 介绍经动脉栓塞介入治疗动静脉畸形(AVM)的方法，总结17例颜面部AVM介入治疗的效果。方法 1998年3月开始采用经皮穿刺股动脉插管，置导管于病变血管团供血动脉处，注入栓塞剂进行栓塞治疗。17例中ll例行单纯栓塞治疗，6例于栓塞后行手术切除。结果 17例患者经介入栓塞治疗后，即时造影均无异常血管显影，临床症状有不同程度的缓解。栓塞后进行手术的患者，出血量明显减少。结论 介入栓塞疗法为动静脉畸形的治疗提供了一个新的途径；手术前栓塞治疗可以明显减少术中的出血，降低手术的危险性。     

脑动静脉畸形并出血的手术治疗

目的探讨脑动静脉畸形(AVM)并出血的手术方法及治疗效果。方法回顾性分析37例脑动静脉畸形并出血病人的临床资料,行血肿清除加AVM切除20例,血肿清除加Ⅱ期AVM切除8例,脑室外引流加Ⅱ期AVM切除5例,血肿清除加去骨瓣减压术4例。结果本组病例存活34例,死亡3例。疗效优23例,良8例,差3例。随访34例,时间6~36月,恢复工作21例,自理生活9例,需要他人照顾4例。结论根据病情选择合适的手术方式能改善预后,血肿清除 AVM切除是该病首选治疗方法。     

颅内动静脉畸形动物模型制作与栓塞的实验研究

目的 探讨颅内动静脉畸形（arteriovenous mal-formation,AVM）动物模型的制作与其在栓塞研究中的应用。方法 以中国实验小型猪（Chinese Experimental Mini-pigs,CEMPs）颅底微血管网（rete mirabile,ReM）为AVM的畸形团,经右颈动静脉吻合并结扎右颈外动脉等建立AVM动物模型,用a-氢基丙烯酸正丁酯（NBCA）胶和Embosphere颗粒分别栓塞,模型建立和栓塞前后行血管造影,并取栓塞组织（ReM)、颈动静脉吻合口和脑做组织病理学检查。结合造影影像和组织病理学发现,探索模型的应用、颈动静脉吻合口的闭塞原因和模型改进方法。结果 在7只CEMPs中成功制作了AVM动物模型,该模型在血管结构、造影影像、栓塞表现和栓塞后病理改变上与人脑AVM的相似。4只动物颈动静脉吻合口血管腔内有血栓形成,其余3只吻合口血管塌陷皱缩,腔内无血栓。死亡动物脑组织病理表现为缺血性梗塞。结论 尽管本方法对于建立颅内AVM动物模型更简单可行,适用于栓塞材料的栓塞研究和介入医师的培训,但该模型仍为急性期模型,其应用十分有限。如何防止模型动静脉吻合口的闭塞和让动物能够耐受栓塞,需要进一步的研究。     

60岁以上患者脑动静脉畸形23例临床分析

目的分析60岁以上患者脑动静脉畸形的特点及治疗策略。方法回顾性分析23例60岁以上脑动静脉畸形患者的临床资料,根据患者病情特点,采取介入栓塞、放射治疗、显微手术及联合治疗等不同的治疗方法,通过随访,分析疗效及预后。结果介入栓塞治疗7例,其中3例为完全栓塞,另外4例部分栓塞后3例择期手术切除,1例接受放射治疗;放射治疗者共5例,其中2例随访过程中出现出血;手术治疗者共15例,其中急诊手术5例,1例患者术后出现再出血,择期手术10例,1例术后出现癫痫发作。所有患者治疗后术前症状得到不同程度改善。结论 60岁以上患者脑动静脉血管畸形有较高出血率,显微手术为主能有效改善患者的生活质量。     

Evaluation of prognostic factors in cerebral arteriovenous malformations

In a retrospective study of 48 patients who underwent elective surgery for cerebral arteriovenous malformations, a statistical analysis of demographic, clinical, and neuroradiological data was undertaken in order to discover the best predictors of operative morbidity. In addition, the predictive value of different clinical grading systems as applied to this series was compared. All patients had a computed tomographic scan and a positive angiogram before surgery. Complete resection was proven angiographically. The univariate Mann-Whitney-Wilcoxon rank sum test, the Fisher exact test, Spearman's rank correlation coefficient analysis, and multivariate logistic regression were used as statistical methods. Duration of surgery, the development, of either new deficits or an increase in the preoperative neurological signs immediately after surgery, and rehabilitation (as measured by the Karnofsky index) were taken as target variables for the difficulty of operation and for postoperative morbidity, respectively. The largest diameter of the nidus of the arteriovenous malformation, eloquence of the adjacent brain, and deep venous drainage showed the most consistent correlation with these target variables. Intracerebral hematoma and other single factors, such as the age of the patient or localization of the arteriovenous malformation did not affect the outcome. The clinical grading scale of Spetzler and Martin provided better prediction of surgical risks than other proposed systems.     

Experience with bucrylate (isobutyl-2-cyanoacrylate) embolization of cerebral arteriovenous malformations during surgery

The clinical experience with five patients selected for embolization of cerebral arteriovenous malformations with bucrylate (isobutyl-2-cyanoacrylate) during surgery is described. Bucrylate embolization was used to obliterate one arteriovenous malformation with a dominant nutrient arterial network, and to facilitate surgical resection in two other cases. The extent of the embolization in one of these cases was limited because of segmental perfusion of the AVM nidus by different nutrient arteries. Histological examination of this arteriovenous malformation, resected 56 days after embolization, suggested bucrylate has minimal histotoxicity. Two arteriovenous malformations were found at operation to be unsuitable for embolization because of technical problems with access and exposure of nutrient arteries, and also because of vagaries in the angiographic data before surgery. In two cases, rapid polymerization of bucrylate resulted in gluing of the injection catheters into the arterial lumen. Two patients experienced transient postoperative neurological deficits after bucrylate embolization. Because of the potential hazards of the technique, direct bucrylate embolization of cerebral arteriovenous malformations should only be considered for those lesions felt unsuitable for direct microsurgical excision, and where facilities exist for recording angiographic data before surgery.     

Treatment of cerebral arteriovenous malformations by neuroradiological intervention and surgical resection

Summary We present the results of a series of 105 patients with cerebral arteriovenous malformations (AVMs) who were treated by a combined protocol including endovascular occlusive measures and open surgical resection. 25 patients were treated only by surgical intervention, 72 patients underwent preoperative endovascular embolization and 8 patients were treated only by embolization, seven of which were only treated for palliation.After superselective angiography the vascular territories suitable for endovascular or microsurgical approach were defined, and in most cases these territories were complementary to each other. In 56 cases, only one embolization was necessary and due to an advantageous co-localization of the departments the whole combined endovascular/neurosurgical procedure was done in one anesthesia. If several endovascular sessions were necessary (16 patients), the resection was mostly carried out immediately after the last neuroradiological session in the same anesthesia with total time of such combined procedure now averaging about 7 hours. According to the proposed grading system by Spetzler we treated 25 grade 1, 24 grade 2, 40 grade 3, 11 grade 4, and 5 grade 5 lesions. The overall success rate defined as complete resection without additional permanent neurological deficit was 89.6% (87 out of 97 surgical cases). The benefits of such combined approach to cerebral AVMs become apparent in shortened and safer surgical procedures as well as in a low complication rate.     

Arteriovenous malformations of the basal ganglia region: Rationale for surgical management

Surgical indications for arteriovenous malformations (AVMs) arising at the region of the basal ganglia are questionable and the majority of cases are considered inoperable. Albeit not free from risks of morbidity and mortality, the treatment of choice is usually radiosurgery for small lesions, and embolization plus radiosurgery for larger lesions. Nevertheless, some lesions may be amenable for surgical resection due to their favorable location. Eighteen cases of such AVMs were selected for a direct approach in our series. Seventeen cases were classified as Spetzler and Martin [22] grade III, and one case was a grade V. Ten patients were males and eight females. The mean age was 28.3 years (ranged from 2 to 43 years). Sixteen patients had had previous hemorrhagic events prior to hospital admission. Eleven patients had pre-operative well stablished neurological deficits, and seven patients although symptomatic had a normal neurological exam at admission. Fifteen patients had their AVMs completely resected. Among the eleven patients with previous neurological deficts nine had no change in their pre-operative condition and two experienced postoperative neurological worsening. In the long-term follow-up six patients had a complete recovery and five recovered only partially. Among the seven patients whose neurological examination was normal pre-operatively five remained unchanged, one had a transient motor deficit, and one died due to a thalamic venous infarction and massive bleeding into the thalamus. The anatomical knowledge and the precise localization of the arteriovenous malformation through the aid of neuroimage studies has provided the means to classify these AVMs and plan operative strategies for some small selected cases with relatively low morbidity.     

Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases

The authors describe their experience with 101 cerebral arteriovenous malformations (AVM's) treated by endovascular embolization followed by surgical removal. Fifty-three patients presented with intracranial hemorrhage and 35 had seizures. Based on the classification of Spetzler and Martin, two AVM's were Grade I, 13 were Grade II, 26 were Grade III, 43 were Grade IV, and 17 were Grade V. Fifty-six AVM's were in the right hemisphere, 28 were in the left hemisphere, 12 were in the corpus callosum, and five involved the cerebellum. In 50 cases, presurgical obliteration of 50% to 75% of the AVM nidus was achieved by embolization, and in 31 cases this percentage increased to between 75% and 90%. In 97 (96%) patients, complete surgical removal of the AVM was obtained. Morbidity resulting from preoperative endovascular embolization was classified as mild in 3.9% of the cases, moderate in 6.9%, and severe in 1.98%. The death rate related to embolization was 0.9%. The immediate postsurgical morbidity was classified as mild in 5.9% of the cases, moderate in 10.8%, and severe in 5.9%. The overall long-term morbidity was mild in 5.9% of the cases, moderate in 6.9%, and severe in 1.98%. Two patients (1.98%) died due to intractable intraoperative hemorrhage and two (1.98%) as a result of postsurgical pulmonary complications.     

Combined treatment effects after embolization and radiosurgery in high-grade arteriovenous malformations. Case report and review of the literature.

In recent years the multimodal therapy concept has been established for high-grade intracerebral arteriovenous malformations (AVM). One strategy of a multimodal treatment approach for patients with AVM (Spetzler grade V) is reported. After endovascular embolization, the patient underwent radiosurgical treatment of the remaining nidus with a linear accelerator, after which he developed a left-sided hemiparesis in conjunction with severe edema. Angiographic control 44 months after radiation showed an occlusion of the radiosurgically treated nidus. The remaining nidus could be removed by microsurgery. The combination of embolization and radiosurgery may provoke prolonged edema and permanent neurological deficits due to inflammatory perivascular changes.     

Preoperative balloon occlusion of arteriovenous malformations

Many materials have been utilized to embolize cerebral arteriovenous malformations (AVMs) preoperatively. Specific vascular anatomy with large feeding vessels deep to the nidus or aneurysms within feeding arteries favor the use of detachable balloons over other embolic agents. Detachable balloons allow test occlusion of a vascular pedicle before permanent occlusion and can obliterate aneurysms in feeding arteries. We describe 36 feeder arterial balloon occlusions performed in 31 patients. Twenty-nine patients subsequently had surgical resection. None of the patients developed normal perfusion pressure breakthrough or required blood transfusions. The preoperative balloon occlusion was judged by the neurosurgeon to decrease significantly the difficulty in surgical resection of the malformation. The remaining 2 patients underwent embolization before radiosurgery. One patient had aneurysms in the feeding artery, which was balloon-occluded to diminish the risk of hemorrhage. There were two neurological deficits and three asymptomatic arterial dissections related to the balloon procedure. Balloon occlusion of feeding arterial pedicles in selected cerebral AVMs may be a valuable surgical adjunct.     

Hematomyelia caused by ruptured intramedullary spinal artery aneurysm associated with extramedullary spinal arteriovenous fistula--case report

A 53-year-old woman presented with a ruptured intramedullary aneurysmal dilatation fed by the anterior spinal artery associated with an arteriovenous malformation located in the ventral cervical spinal cord. She developed tetraparesis and respiratory dysfunction. The neurological deterioration was caused by hematomyelia due to the ruptured aneurysmal dilatation and progression of edema in the upper cervical spinal cord due to venous hypertension associated with additional hematoma in the medulla oblongata. Endovascular embolization of both C-1 and C-2 radicular arteries was performed with Guglielmi detachable coils, but components fed by small branches such as the radiculo-pial artery were not obliterated. Surgery was performed for extirpation of the arteriovenous malformation and cervical intramedullary hematoma, and excision of the aneurysmal dilatation through a transcondylar approach combined with vertebral artery transposition. Postoperatively, she overcame several complications such as pneumonia and endocarditis, and had only moderate weakness of the right upper and lower limbs. This case indicates that surgical intervention for high cervical intramedullary lesion may be very effective.     

Intra-Operative Colour-Duplex-Sonography in the Surgical Management of Cerebral AV-Malformations

Summary  In this prospective study the role of intra-operative Colour-Duplex-Sonography (=CDS) during surgery of arteriovenous malformations (=AVM) is evaluated.  During the last three years 20 consecutive patients with supratentorial AVMs were examined by intra-operative CDS in order to evaluate the potential of CDS to 1) localize the AVM, 2) differentiate between embolized and perfused parts, 3) identify feeding and draining vessels and 4) control the complete excision of the AVM.  All AVMs were localized supratentorially, 9 were grade I and II (according to Spetzler and Martin [31]), 8 grade III and 3 grade IV. 11 were partly embolized and 8 associated with an intracerebral bleeding.  In all cases the nidus was correctly localized sonographically by its typical bidirectional flow pattern in Colour-mode. CDS guided the surgeon directly to all (11 cases) deep-seated AVMs (2 to 4cm subcortically). The smallest nidus measured 10 mm.  28 of 34 angiographically defined main feeding and 18 of 23 draining vessels were identified. 14 patients were controlled sonographically at the end of the resection regarding the completeness of excision. In 11 patients CDS was negative and was confirmed by either postoperative angiography or MRI in 10 patients. In one case residual AVM tissue was missed by CDS. Positve CDS findings in 3 cases were all confirmed by microscopic re-inspection, angiography and CCT.  Our results suggest that CDS is able to localize AVMs intra-operatively with minimal instrumentation. It allows safe navigation to deep-seated malformations with high accuracy. Feeding and draining vessels can be identified and completeness of resection can be controlled.     

Intraoperative angiography in the surgical treatment of cerebral arteriovenous malformations and fistulas

Summary ?Background. The role of intraoperative angiography in the surgical treatment of cerebrovascular malformations remains controversial. The authors report on their experiences with intraoperative angiography in a series of 20 cases with cerebrovascular malformation to determine whether the use of intraoperative angiography has a favorable impact on the surgical treatment of cerebrovascular malformations. Methods. Intraoperative angiography was performed in the surgical resection of arteriovenous malformation in 18 patients and in the surgical obliteration of arteriovenous fistula in 2 patients. The incidence of unexpected findings, such as residual nidus, demonstrated by intraoperative angiography was determined. Findings. High-quality subtraction images were obtained by intraoperative angiography in every case and the findings prompted an additional procedure in 1 case that displayed an unexpected residual nidus (5.6%). There were no complications from the intraoperative angiography procedure. Interpretation. Intraoperative assessment of technical results prior to wound closure offers the neurosurgeon the opportunity to resect or obliterate a vascular malformation completely, obviating a second operation. Published online May 19, 2003