介入栓塞联合显微外科手术治疗硬脑膜动脉参与供血的高级别脑动静脉畸形单中心临床疗效

Single center clinical efficacy of endovascular embolization combined with microsurgical resection in treatment of high-grade arteriovenous malformation with dural artery supply

目的分析硬脑膜动脉供血的高级别脑动静脉畸形(AVM)患者的临床特点,探讨介入栓塞联合显微外科手术治疗的临床疗效。方法回顾性分析7例合并硬脑膜动脉供血的高级别脑AVM患者的临床资料,其中首发症状表现为头痛4例,意识障碍1例,肢体无力1例,顽固性癫痫1例。Spetzler-Martin分级Ⅳ6例,Ⅴ级1例。所有患者均Onyx-18胶栓塞硬脑膜供血动脉和/或部分高流量的颅内供血动脉、深部供血动脉,栓塞术后48 h内行显微外科手术切除脑AVM,术后1周复查脑血管造影评估手术切除效果。结果6例患者成功栓塞10支硬脑膜动脉及其对应的畸形团,1例患者仅栓塞供血动脉近端,同时栓塞4例大脑后动脉(其中1例有血流动力学相关性动脉瘤),2例大脑前动脉分支(1例有血流动力学相关性动脉瘤),1例小脑上动脉。所有患者AVM均被完全切除。1例患者肌力较术前下降,2例出现颅内感染。临床随访7例,改良Rank评分0~1分7例,6例血管造影复查AVM未显影。结论硬脑膜动脉供血的脑AVM以高级别多见,同时兼备脑AVM和硬脑膜动静脉瘘的临床表现,显微外科手术前行介入栓塞治疗能降低手术并发症,提高临床疗效。

Objective To analyze the clinical characteristics of patients with high-grade cerebral arteriovenous malformation(AVM)combined with transdural artery blood supply and to explore the clinical effect of embolization combined with microsurgery.Methods The clinical data of 7 patients with high-grade cerebral AVM complicated with dural artery blood supply were analyzed retrospectively.The preliminary symptom was headache in 4 cases,disturbance of consciousness in 1 case,limb weakness in 1 case and intractable epilepsy in 1 case.There were 6 cases of Spetzler-Martin gradeⅣand 1 case of gradeⅤ.All patients were embolized with Onyx-18 glue in dural blood supply arteries and/or some high flow intracranial blood supply arteries and deep blood supply arteries.Microsurgery was performed to remove cerebral AVM within 48 hours after embolization.Cerebral angiography was rechecked one week after operation to evaluate the effect of surgical resection.Results 6 patients successfully embolized 10 dural arteries and their corresponding malformations.1 patient only embolized the proximal end of the blood supply artery,while embolizing 4 posterior cerebral arteries(including 1 hemodynamic related aneurysm),2 anterior cerebral artery branches(1 hemodynamic related aneurysm),and 1 superior cerebellar artery.All patients with AVM were completely removed.The muscle strength of 1 patient decreased compared with that before operation,and 2 patients had intracranial infection.7 cases were followed up,7 cases had a modified Rank score of 0-1,and 6 cases had AVM without development by angiography.Conclusions Cerebral AVM supplied by dural artery are common in high-grade,and have the clinical manifestations of cerebral AVM and dural arteriovenous fistulas.Interventional embolization before microsurgery can reduce surgical complications and improve clinical efficacy.