栓塞治疗脑动静脉畸形中血管构筑分级系统的意义

A proposed angioarchitecture grading system related to embolization of brain arteriovenous malformations

目的分析脑动静脉畸形(AVM)经α-氰基丙烯酸正丁酯(NBCA)栓塞治疗的风险;研究影响栓塞效果的血管构筑因素,建立脑 AVM 血管内治疗的分级系统。方法回顾性分析189例经NBCA 栓塞治疗的脑 AVM 患者的临床资料、血管特征、栓塞并发症以及栓塞的程度。采用多元回归分析,探寻血管构筑特性与 NBCA 栓塞治疗脑 AVM 的栓塞效果及并发症发生率间的关系,基于畸形的大小[(纯动静脉瘘)为0分、畸形血管团最大径<30 mm 为1分、≥30 mm 为2分],一级供血动脉数(1根为0分、2～3根为1分、≥4根为2分),二级供血动脉数(≤3根为0分、≥4根为1分)建立血管构筑分级系统,分级系统根据积分的高低分为6级(0～Ⅴ级)。结果 189例脑 AVM 患者,共行324次 NBCA 栓塞治疗;手术相关病死率为1.6%(3/189),永久神经功能缺损性并发症的发生率为2.6%(5/189)。31例纯动静脉瘘和Ⅰ级 AVM 完全栓塞24例(77.4%);101例Ⅳ级、Ⅴ级的 AVM 患者82例(81.2%)栓塞程度在50%以下,没有完全栓塞病例,分级与栓塞程度的吻合度较强(κ=0.736,P<0.01)。结论血管构筑评级系统能很好地预测 NBCA 栓塞治疗脑 AVM 的难度及效果。结合 AVM 的 Spetzler,评分,可以更合理地制定治疗方案。

Objective To analyze the risk of embolization of brain AVMs, study the angioarchitectural factors affecting the difference of embolization level, and to establish the angioarchitecture grading system for embolization of brain AVMs. Methods The clinical data, angioarchitectural features, embolism complication and embolism level were retrospectively analyzed. Multivariate statistical analysis was performed to determine if any of the variables was predictive of a poor outcome of embolization （ death or permanent neurological deficit）, and if any of the variables was predictive of the percentage obliteration achieved by embolization. Based on the above results, we established the angioarchitecture grading system. Results Endovascular procedures for embolization were performed 324 times in 189 patients during an ll-year period. Embolization was performed using N-butyl cyanoacrylate. In those patients, 3（ 1.6% ） died and 5（2. 6% ） had a permanent neurological deficit as a result of the embolization. The AVMs were given a score from 0 to 5 based on the size, number of the first grade feeding artery, and number of the second grade feeding artery. The assigned scores were as follows ： nidus size （ AVF = 0, 〈 30 mm= 1, ≥ 30 mm = 2）, number of the first grade feeding artery （ 1 = 0, 2 - 3 = 1, ≥4 = 2） and number of the second grade feeding artery（ ≤3 =0, ≥4 = 1 ）. Angiographic results based on percentage obliteration were grouped into four categories： complete, 80%-99%, 50%-79%, and 0%-50% . In the AVMs with angioarchitecture scores 0-1, 24（77.4% ） of 31 were fully embolised, with scores of 4-5, none of the 101 were fully embelised, 82（81.2% ）were below 50% embelization percentage. The correlation between the angioarchitecture grading system and the embolization percentage was strong （ κ = 0. 736, P 〈 0. 05 ）. Conclusions The angioarchitecture grading system predicts the embolization percentage perfectly. The lower the scores, the higher the possibility of fully embolization is; the higher the scores, the lower the embolization percentage is. Combining the angioarchitecture grading system and the Spetzler grading system, we can make more rational treatment strategy for brain AVMs.