Duffau H, Lopes M, Janosevic V, Sichez J P, Faillot T, Capelle L, Ismaïl M, Bitar A, Arthuis F, Fohanno D
Department of Neurosurgery, Hôpital de la Salpêtrière, Paris, France.
J Neurosurg. 1999 Jan;90(1):78-84. doi: 10.3171/jns.1999.90.1.0078.
In this study the authors sought to estimate the frequency, seriousness, and delay of rebleeding in a homogeneous series of 20 patients whom they treated between May 1987 and May 1997 for arteriovenous fistulas (AVFs) that were revealed by intracranial hemorrhage (ICH). The natural history of intracranial dural AVFs remains obscure. In many studies attempts have been made to evaluate the risk of spontaneous hemorrhage, especially as a function of the pattern of venous drainage: a higher occurrence of bleeding was reported in AVFs with retrograde cortical venous drainage, with an overall estimated rate of 1.8% per year in the largest series in the literature. However, very few studies have been designed to establish the risk of rebleeding, an omission that the authors seek to remedy.
Presenting symptoms in the 20 patients (17 men and three women, mean age 54 years) were acute headache in 12 patients (60%), acute neurological deficit in eight (40%), loss of consciousness in five (25%), and generalized seizures in one (5%). Results of the clinical examination were normal in five patients and demonstrated a neurological deficit in 12 and coma in three. Computerized tomography scanning revealed intracranial bleeding in all cases (15 intraparenchymal hematomas, three subarachnoid hemorrhages, and two subdural hematomas). A diagnosis of AVF was made with the aid of angiographic studies in 19 patients, whereas it was a perioperative discovery in the remaining patient. There were 12 Type III and eight Type IV AVFs according to the revised classification of Djindjian and Merland, which meant that all AVFs in this study had retrograde cortical venous drainage. The mean duration between the first hemorrhage and treatment was 20 days. Seven patients (35%) presented with acute worsening during this delay due to radiologically proven early rebleeding. Treatment consisted of surgery alone in 10 patients, combined embolization and surgery in eight, embolization only in one, and stereotactic radiosurgery in one. Three patients died, one worsened, and in 16 (80%) neurological status improved, with 15 of 16 AVFs totally occluded on repeated angiographic studies (median follow up 10 months).
The authors found that AVFs with retrograde cortical venous drainage present a high risk of early rebleeding (35% within 2 weeks after the first hemorrhage), with graver consequences than the first hemorrhage. They therefore advocate complete and early treatment in all cases of AVF with cortical venous drainage revealed by an ICH.
在本研究中，作者试图评估1987年5月至1997年5月间他们治疗的20例因颅内出血（ICH）而发现的动静脉瘘（AVF）患者再出血的频率、严重程度及延迟情况。颅内硬脑膜动静脉瘘的自然病史仍不清楚。在许多研究中，人们试图评估自发性出血的风险，尤其是作为静脉引流模式的函数：据报道，皮质静脉逆行引流的AVF出血发生率较高，在文献中最大的系列研究中，总体估计年发生率为1.8%。然而，很少有研究旨在确定再出血的风险，作者试图弥补这一疏漏。
20例患者（17例男性，3例女性，平均年龄54岁）表现出的症状为：12例（60%）有急性头痛，8例（40%）有急性神经功能缺损，5例（25%）有意识丧失，1例（5%）有全身性癫痫发作。5例患者临床检查结果正常，12例有神经功能缺损，3例昏迷。计算机断层扫描显示所有病例均有颅内出血（15例脑实质内血肿，3例蛛网膜下腔出血，2例硬膜下血肿）。19例患者通过血管造影研究确诊为AVF，其余1例为围手术期发现。根据Djindjian和Merland的修订分类，有12例III型和8例IV型AVF，这意味着本研究中的所有AVF均有皮质静脉逆行引流。首次出血与治疗之间的平均间隔时间为20天。7例患者（35%）在此延迟期间因经放射学证实的早期再出血而出现急性病情恶化。10例患者仅接受手术治疗，8例接受栓塞与手术联合治疗，1例仅接受栓塞治疗，1例接受立体定向放射外科治疗。3例患者死亡，1例病情恶化，16例（80%）神经功能状态改善，16例中有15例AVF在重复血管造影研究中完全闭塞（中位随访10个月）。
作者发现，皮质静脉逆行引流的AVF有早期再出血的高风险（首次出血后2周内为35%），其后果比首次出血更严重。因此，他们主张对所有因ICH而发现的有皮质静脉引流的AVF病例进行早期彻底治疗。
