复合手术治疗脑动静脉畸形的效果及症状进展分析:一项单中心回顾性队列研究

Analysis of the effect and symptom progression of hybird surgery for cerebral arteriovenous malformation:a single-center retrospective cohort study

目的探讨复合手术治疗脑动静脉畸形(CAVM)的安全性与有效性以及术后症状进展的可能因素。方法回顾性连续纳入2016年1月1日至2021年12月31日入住首都医科大学宣武医院神经外科并接受复合手术治疗的61例CAVM患者,记录其人口学信息(性别、年龄)、发病情况[首次通过影像学检查诊断CAVM和(或)首次出现出血、癫痫等CAVM相关症状]、起病至复合手术时间、入院时改良Rankin量表(mRS)评分、既往CAVM治疗史(既往CAVM外科手术切除以及血管内栓塞治疗情况)、CAVM影像学资料(病变大小、位置、引流情况)、Spetzler-Martin分级、病变致密程度(疏松、致密)、CAVM合并动脉瘤或动脉瘤样结构、手术方式(显微外科手术+术中DSA、显微外科手术+术中DSA+术中血管内栓塞)、治疗相关并发症[手术相关区域的颅内出血和(或)缺血事件和(或)水肿、穿刺点血肿和(或)瘘和(或)假性动脉瘤、治疗相关感染、消化道出血和(或)牙龈出血和(或)鼻衄、对比剂过敏、全因死亡]、临床及影像学随访资料。评估复合手术治疗的安全性[治疗相关并发症、症状进展(术后6个月的mRS评分减去治疗前mRS评分的差值为正值)]与有效性[闭塞(术后6个月DSA显示原畸形团部位完全不显影为闭塞)、预后良好(术后6个月mRS评分≤2分)]。依据术后6个月临床随访结果显示症状是否进展,将接受复合手术治疗的CAVM患者分为进展组和无进展组,并比较两组患者的基线及临床特征。结果(1)61例接受复合手术治疗的CAVM患者中,男性37例(60.7%),中位年龄25(13,42)岁;无症状患者11例(18.0%),以出血为首发症状的患者39例(63.9%),以癫痫为首发症状的患者11例(18.0%);入院时mRS评分≤2分者54例(88.5%),既往接受血管内栓塞治疗后残余或复发的CAVM患者38例(62.3%);CAVM病变Spetzler-Martin分级Ⅰ、Ⅱ、Ⅲ、Ⅳ级分别为13例(21.3%)、22例(36.1%)、21例(34.4%)、5例(8.2%);24例患者应用复合手术平台进行了术中DSA验证,37例患者应用复合手术平台进行了术中DSA验证及辅助血管内栓塞治疗。(2)临床随访完成率77.0%(47/61),随访时间6~24个月,中位随访时间12(6,24)个月;预后良好率为91.5%(43/47),无死亡患者;治疗相关并发症发生率10.6%(5/47)。影像学随访完成率为72.1%(44/61),中位随访时间15(10,22)个月;CAVM闭塞40例(90.9%),CAVM残留和复发各2例(4.5%)。(3)47例完成临床随访的患者中有15例患者出现症状进展,32例患者症状无进展。两组患者性别、年龄、起病症状、入院时mRS评分、病变位置、病变致密程度、合并动脉瘤或动脉瘤样结构的组间差异均无统计学意义(均P>0.05);进展组病变最大直径<3、3~6、>6 cm的占比分别为3/15、10/15、2/15,以最大直径3~6 cm为主;无进展组最大直径<3、3~6 cm的占比分别为18/32、14/32,以最大直径<3 cm为主(χ^(2)=8.321),进展组病变存在深静脉引流(χ^(2)=11.937)及残留和(或)复发(χ^(2)=8.507),组间差异均有统计学意义(均P<0.05)。结论复合手术治疗CAVM具有一定的安全性与有效性。复合手术治疗后出现病情进展的CAVM患者具有病变最大直径较大、存在深静脉引流、病变残留和(或)复发的特点,影响病情进展的因素有待于未来进一步探讨。

Objective To investigate the safety and efficacy of bybrid surgery in the treatment of cerebral arteriovenous malformation(CAVM)and possible factors for postoperative symptom progression.Methods A total of 61 patients with CAVM admitted to the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University from January 1,2016 to December 31,2021 who underwent bybrid surgery were retrospectively included.Demographic information(sex,age),incidence(first diagnosis of CAVM by imaging and/or first appearance of CAVM-related symptoms such as hemorrhage and epilepsy),time from onset to hybrid surgery,modified Rankin scale(mRS)score at admission,history of previous CAVM treatment(surgical removal of previous CAVM and intravascular treatment),CAVM imaging data(lesion location,size,drainage),Spetzler-Martin grade,lesion density(loose,dense),CAVM combined with aneurysm or aneurysmal structure,surgical method(microsurgery+intraoperative DSA,microsurgery+intraoperative DSA+endovascular embolism),treatment-related complications(intracranial hemorrhage and/or ischemic events and/or edema in surgery-related areas,puncture site hematoma and/or fistula and/or pseudoaneurysm,gastrointestinal and/or gingival bleeding and/or epistaxis,contrast hypersensitivity,all-cause death),clinical and radiological follow-up data were recorded.The safety(treatment-related complications,symptom progression[positive difference between the mRS score at 6 months postoperatively and the baseline mRS score])and effectiveness(occlusion,complete absence of the malformation on DSA at 6 months postoperatively;good prognosis,mRS score≤2 at 6 months postoperatively)of hybrid surgery treatment were evaluated.Based on the clinical follow-up results at 6 months after surgery,patients who underwent hybrid surgery for CAVM were divided into the progressive group and the non-progressive group,and their baseline and clinical characteristics were compared.Results(1)Among the 61 patients who underwent hybrid surgery for CAVM,37(60.7%)were male,with a median age of 25(13,42)years;11(18.0%)were asymptomatic,and 39(63.9%)had hemorrhage as their initial symptom,while 11(18.0%)had seizures as their initial symptom.At admission,54(88.5%)patients had an mRS score of≤2,including 38(62.3%)patients who had undergone previous endovascular embolization and had residual or recurrent CAVM;the Spetzler-Martin grade of the CAVM lesion wasⅠ,Ⅱ,Ⅲ,orⅣin 13(21.3%),22(36.1%),21(34.4%),and 5(8.2%)patients,respectively;24 patients underwent DSA verification during surgery using a hybrid surgical platform,and 37 patients underwent DSA verification and assisted endovascular embolization using a hybrid surgical platform.(2)Clinical follow-up completion rate was 77.0%(47/61);the follow-up time ranged from 6 to 24 months and the median follow-up time was 12(6,24)months.The good prognosis rate was 91.5%(43/47),there was no death.The incidence of treatment-related complications was 10.6%(5/47).The completion rate of imaging follow-up was 72.1%(44/61)and the median follow-up time was 15(10,22)months.There were 40(90.9%)of CAVM occlusion,2(4.5%)of residual CAVM and 2(4.5%)of recurrent CAVM.(3)Among the 47 patients who completed clinical follow-up,15 patients developed symptoms and 32 patients did not develop symptoms.There were no significant differences in sex,age,onset symptoms,mRS score at admission,lesion location,lesion density and aneurysm or aneurysmal structure between the two groups(all P>0.05).In the progressive group,the proportion of lesions with the largest diameter<3 cm,3-6 cm and>6 cm were 3/15,10/15 and 2/15,respectively,and the largest diameter was mainly 3-6 cm.In the non-progressive group,the proportion of the largest diameter<3 cm and 3-6 cm were 18/32 and 14/32,respectively,and the largest diameter<3 cm was the main proportion(χ^(2)=8.321).Deep venous drainage(χ^(2)=11.937)and residual and/or recurrence(χ^(2)=8.507)were present in the progressive group,and the differences between the groups were statistically significant(all P<0.05).Conclusions Hybrid surgery has certain safety and effectiveness in the treatment of CAVM.Patients with CAVM who experienced progression after undergoing composite surgery have characteristics such as larger maximum diameter,the presence of deep venous drainage and residual and/or recurrence,and the factors affecting progression need to be further explored in the future.