【作者】 罗斌；

【导师】 段传志；

【作者基本信息】 南方医科大学 ， 外科学， 2013， 博士

【摘要】 研究背景脑动静脉畸形是由于缺乏正常的毛细管床,脑的动脉血管和静脉血管之间直接形成血管篓的血管异常,在脑血管造影上,AVM多表现为扩张的供血动脉和扭曲变形的引流静脉相互缠绕紧密结合在一起的团块。动静脉异常分流,病灶引流静脉提前显影是脑动静脉畸形的特点。AVM发病的主要症状是出血、癫痫和头痛及其他局灶性神经功能障碍,可以单独存在,也可合并发生。Brown RD Jr等对特定人群的27年的研究报道,脑AVM的病人中65%首发症状表现为出血,所有出血病人中按出血人数的多少依次为脑实质出血、蛛网膜下腔出血、脑室出血或这些部位的混和性出血。C Stapf等对纽约890万人口在1996年到1999年的脑动静脉畸形诊断病例的回顾性研究的报告中,首次确诊为脑出血的脑动静脉畸形占所有病人的33%。Poyee Tung等人发现,病变一旦出血,说明病灶血管结构已处于不稳定状态,容易发生再次出血。本研究回顾性统计分析珠江医院2001-1至2012-1脑动脉畸形合并出血患者相关危险因素,采用统计学方法,明确动静脉畸形出血原因及有主要预警作用的因素,同时探讨不同治疗栓塞剂型对动静脉畸形治疗效果,及评价其疗效。第一章脑动静脉畸形出血相关因素分析研究背景脑AVM最严重和最常见的症状是颅内出血,导致脑动静脉畸形出血的原因众多,可能与出血相关的临床危险因素有年龄、性别、高血压、高血脂、高血糖,与血管构筑因素相关因素有畸形部位、大小、供血动脉的来源、数量、扭曲程度、直径、供血方式、畸形团的位置、大小、形态、引流静脉的数量、直径、引流方式、引流路径、是否伴随的血管瘤等等,但目前缺乏系统性的研究分析,因此,有必要全面深入探讨脑AVM的出血危险因素。目的探讨临床和血管构筑相关因素对脑动静脉畸形出血的影响。方法珠江医院近十年以来临床资料及影像学资料齐全的诊断为脑AVM的患者共计312例,脑出血组AVM(病例组)168例,其中男性86例,女性82例,年龄12-68岁,非脑出血组(对照组,患者以癫痫、头痛、神经功能缺失为发病症状)144例,男性81例,女性63例,年龄8-71岁。分析比较两组间临床相关风险因素年龄、性别、高血压、高血脂、高血糖、妊娠以及血管构筑相关风险因素AVM部位、大小、形态、供血动脉类型、引流静脉类型、伴随动脉瘤等的差异,先采用单因素分析,筛选出相关的危险因素,再用多因素logistic回归分析上述因素与脑AVM出血的关系,总结脑AVM出血的主要风险因素及保护性因素。结果AVM直径≧6cm(OR2.006,95%C.I1.286-3.128),深部静脉引流(OR1.679,95%C.I1.146-2.460),单支引流静脉引流(OR3.684,95%C.I2.554-5.315)位于深部的(OR2.372,95%C.I1.175-4.787),患有高血压(OR3.433,95%C.I1.812-6.503)是脑动静脉畸形出血的危险因素。结论位于深部、大型、单一静脉引流、引流方式为深部引流以及高血压为脑动静脉畸形破裂出血的危险因素。第二章脑动静脉畸形的血管内栓塞治疗研究背景目前对于脑动静脉畸形的治疗手段主要有手术治疗、血管内介入治疗、放射治疗。上述治疗方术即可相互结合,也可单独采取其中之一的治疗方式。随着新型血管内栓塞剂ONXY及Glubran的广泛使用,以及较好的治疗效果,血管内栓塞治疗越来越成为脑动静脉畸形主要的治疗方式。目的探讨ONXY和Glubran两种不同栓塞剂在不同分级的脑动静脉畸形的栓塞方法及比较它们的疗效、优缺点。方法选取2006年1月一2012年1月在南方医科大学珠江医院神经外科住院行介入治疗的脑动静脉畸138例,均为单一动静脉畸形。其中经Glubran栓塞治疗组78例,总共146次栓塞,ONYX栓塞治疗组60例,112次栓塞,男性86例,女性52例,年龄8-67岁,平均36.5岁。回顾分析患者住院记录、手术记录、脑血管造影资料(包括随访的造影资料),分析比较ONYX和Glubran不同栓塞方法及治疗效果、并发症。结果两者栓塞的完全闭塞率,ONYX为29%,glubran为31%,两者之间无显著差异,次全闭塞率为两者对小型、供血类型简单的动静脉畸形都能取得较好的闭塞治疗效果,分级较高供血复杂的动静脉畸形两者治疗效果相似,粘管等并发症ONYX较Glubran高。结论在脑动静脉畸形的栓塞治疗中,ONYX及Glubran的总体治愈率相似。两者都可以做为脑AVM血管内栓塞的栓塞剂的选择。更多还原

【Abstract】 BackgroundCerebral arteriovenous malformation is the most common cerebral vascular dysplasia due to the lack of normal capillary bed. Angiographically, AVM is characterized by the performance of feeding arteries expansion and draining veins distorted mutual interlaced closely together clumps. It is characterized by abnormal arteriovenous shunt the angiographical early developing of lesion draining veins.Its main symptoms are the onset of bleeding, epilepsy, headache and other focal neurological dysfunction. Brown RD reported that the first symptom was bleeding. Among them, the most symptoms was bleeding in brain tissue, the2nd was subarachnoid hemorrhage, and the remaining was intraventricular hemorrhage or mixture of bleeding. C Stapf had the retrospective study of brain arteriovenous malformation at the New York population of8.9million from1996to1999. He found that the1st diagnosed cerebral arteriovenous malformation cases were accounted for33%of all patients. Foster et al found that, once the bleeding lesions, the cAVM is prone to bleeding again due to lesions vascular structure in an unstable state, In this study, we retrospective collected the large number of cAVM cases from 2001-1to2012-1in Zhujiang Hospital and make the statistical analysis on the risk factors of intracranial hemorrhage after embolization of cerebral arteriovenous malformation, and evaluated the therapeutic efficacy using different sembolism materials for the purpose of guiding the clinical prevention and treatment decision making in the future.The first chapterFactors of cerebral arteriovenous malformation hemorrhageBackgroundThe most serious and the most common symptoms of Cerebral AVM is intracranial hemorrhage. There are many kind of reasons for cerebral arteriovenous malformation hemorrhage, which may be related to age, sex, hypertension, high cholesterol, high blood sugar, angioarchitecture factors associated with vascularfactors deformity, the size of the feeding artery of the source, quantity, level of distortion, the diameter of the blood supply to the way the location of the malformation, size, shape, number of draining veins diameter, drainage, drainage path, whether accompanied by hemangiomas, and so on. However, there is lack of systematic research and analysis. It is necessary to the full depth study on brain AVM hemorrhage risk factors.ObjectionTo Investigate the clinical and angioarchitecture relevant factors of cerebral arteriovenous malformation hemorrhage.Methods and materials312patients with arteriovenous malformations were diagnosed in Zhujiang Hospital, nearly ten years with complete clinical data and imaging data.168cases in hemorrhage group (case group), male86case, female82cases, age range from12to68years old.144cases in non-cerebral hemorrhage group (control group, patients with epilepsy, headache, nerve function missing for the onset of symptoms), male81cases, female63cases, range from8to71years old,. There were compared between the two groups clinically relevant risk factors of age, gender, hypertension, high cholesterol, high blood sugar, pregnancy and angioarchitecture risk factors associated with AVM location, size, shape, type of feeding artery, draining vein type, accompanied by aneurysm differences,and then using logistic regression analysis of the relationship between the above factors with brain AVM bleeding, summarizes the major risk factors and protective factors for cerebral AVM hemorrhage.ResultsAVM diameter is≧6cm (OR2.006,95%CI1.286-3.128), deep venous drainage (OR1.679,95%CI1.146-2.460), single venous drainage (OR3.684,95%CI2.554-5.315) indeep (OR2.372,95%CI1.175-4.787), with high blood pressure (OR3.433,95%CI1.812-6.503) were risk factors for cerebral arteriovenous malformation hemorrhage.ConclusionLarge and Deep-seated AVM and cAVM with the single deep venous drainage were the independent risk factors of cerebral AVM hemorrhage. The second chapterEndovascular embolization of Cerebral artcriovenous malformationsBackgroundThere were four kinds of treatment strategies for cerebral arteriovenous malformation:Surgery, endovascular treatment, radiation therapy and conservative treatment, which can be used alone or combined with each other. With the extensive use of the novel intravascular embolic agent like onyx and Glubran with a wonderful therapeutic effect, endovascular embolization has increasingly become the main treatment of cerebral arteriovenous malformations.ObjectionTo investigate the efficacy, advantages and disadvantages between onyx and Glubran in the treatment of brain arteriovenous malformation in different classification.Method138cases with arteriovenous malformations Selected from Zhujiang Hospital neurosurgery inpatient, interventional treatment of brain arteriovenous malfomatoin January2006.1to January2012.1.78cases with Glubran embolization in the treatment group, total of146times embolism.60patients with ONYX embolization,112times embolism.86male,52female, age range from8to67years old, an average of36.5years. Recalling the analysis of hospitalization records, surgical records,cerebral angiography (including follow-up angiography), analysis comparing ONYX and different Glubran embolism and treatment effects, complications.Results Complete occlusion rate was similar tin both of Glubran and Onyx.29%was in Onyx group and31%in glubran group with no significant difference. Subtotal occlusion rate was simple and small in both of them, the blood supply to the type of arteriovenous malformations can achieve better occlusion The therapeutic effect of graded higher blood supply with the complex arteriovenous malformation was similar in both group. The stick tube complication in Onyx group was higher than in Glubran group.ConclusionOnyx and glubran had the same cure rate in the treatment of cerebral AVM. Both of them can be facultative.更多还原