不同方法测量颅内动静脉畸形与功能区的距离对术后神经功能缺损的预测作用

Roles of different methods in measurement of distance between intracranial arteriovenous malforma-tion and eloquent cortex in prediction of postoperative neurological deficits

目的探讨不同方法测量颅内动静脉畸形(iAVM)的病灶与功能区的距离(LED)对手术相关神经功能障碍(SFD)的预测作用。方法回顾性分析首都医科大学附属北京天坛医院神经外科2017年1月至12月行显微手术切除术的96例iAVM患者的临床资料。根据术前、术后3个月改良Rankin量表评分(mRS)的变化(差值≥1分)将患者分为SFD组17例,无SFD组79例。根据Spetzler-Martin(S-M)标准定义功能区。首先基于术前T1和T2加权成像、时间飞跃法成像、功能磁共振成像及弥散张量成像重建病灶和功能区,然后采用传统和改良的方法测量LED(分别简称传统LED和改良LED)。采用多因素logistic回归分析等方法分析影响术后3个月SFD的危险因素,采用受试者工作特征曲线(ROC)判断不同方法测量的功能区在预测SFD中的作用。结果多因素logistic回归分析显示,S-M分级(OR=3.10)、改良LED(OR=0.66)、病灶类型(弥散型和非弥散型)(OR=0.12)是术后SFD的独立预测因素(均P<0.05)。对于所有患者,改良LED和传统LED预测发生SFD的作用均较好[曲线下面积(AUC)分别为0.843、0.830;均P<0.05],以S-M标准确定的功能区对发生SFD无预测作用(AUC=0.516,P=0.804)。对于非弥散型iAVM患者,传统LED和改良LED预测SFD的价值均较高(AUC分别为0.784、0.726,均P<0.05);对于弥散型iAVM患者,改良LED预测SFD的作用较好(AUC=0.833,P=0.003),而传统LED的预测作用差(AUC=0.583,P=0.665)。结论LED是影响iAVM患者手术预后的重要因素。对于非弥散型iAVM,传统LED和改良LED均有较好的预测价值,对于弥散型iAVM,仅改良LED具有预测作用。

Objectives To explore the predictive values of different methods measuring the distance between lesion and eloquent cortex(LED)in surgery-related functional deficit(SFD)in intracranial arteriovenous malformations(iAVMs).Methods This study retrospectively reviewed and followed up the patients who underwent microsurgical resection of iAVMs at Department of Neurosurgery,Beijing Tiantan Hospital,Capital Medical University from January to December 2017.Based on the difference(≥1)between the mRS(modified Rankin scale)at 3 months after surgery and that prior to surgery,17 patients were categorized into the SFD group and 79 into non-SFD group.The eloquent cortex was firstly recognized according to the Spetzler-Martin(S-M)standard.Based on the presurgical T1-weight,T2-weight,time-of-flight,functional and diffuse tensor imaging MR,the LED and modified LED(MLED)were measured.Multivariate logistic analysis was performed to investigate the independent risk factors related to SFD at 3 months post surgery.The ROC(receiver operating characteristic)curve analysis was performed to explore the predicting values of different measuring methods in SFD.Results Multivariate logistic analysis based on 96 patients demonstrated that the S-M grading(OR=3.10),MLED(OR=0.66)and nidus type(diffuse and compact,OR=0.12)were independent risk factors for SFD(all P<0.05).For all iAVMs,both MLED and LED had good predictive value in SFD,and the AUC(area under a curve)values were 0.843 and 0.830 respectively(both P<0.05),while the S-M grading(AUC:516,P=0.804)did not have predictive value.For compact iAVMs,LED(AUC=0.784)and MLED(AUC=0.726)could effectively predict the risk of SFD(all P<0.05).For diffuse iAVMs,MLED(AUC=0.833)could predict the risk of SFD(P=0.003),whereas LED(AUC=0.583,P=0.665)had poor predicting value.Conclusions The distance between iAVM and eloquent cortex seems to be an important factor to predict the surgical outcome.For compact iAVM,both LED and MLED have good predicting values,while only MLED shows predicting value for diffuse iAVM.