Nataf F, Merienne L, Schlienger M
Service de Neurochirurgie, Centre Hospitalier Sainte-Anne, 1, rue Cabanis, 75674 Paris Cedex 14.
Neurochirurgie. 2001 May;47(2-3 Pt 2):298-303.
Treatment of large cerebral arteriovenous malformations is a challenge for embolization, surgery and radiosurgery too. The purposes of this study is to review results of RS for these large cerebral arteriovenous malformations and to study recent methods which can allow to improve results.
and method. From our series, 112 patients had cerebral arteriovenous malformations higher than 30 mm or 10 cc at time of the radiosurgery. Revelation mode was hemorrhage in 47%, seizures in 42%, headaches in 16%, and progressive neurological deficits in 7%. Discovery was fortuitous in 2.7% of cases. Before radiosurgery, 57% were embolized, 5% were operated, 4.5% were reirradiated and 1.8% were operated and embolized. Distribution according to Spetzler & Martin's grade was following: 0% in grade I, 12% in grade II, 41% in grade III and 46% in grade IV. No patient was in grade V.
Global obliteration rate was 39% for large cerebral arteriovenous malformations. In multivariate analysis, only recovering (positive correlation), and previous embolization (negative correlation) were correlated with obliteration rate.
Current procedures of radiosurgery allow obliteration in a limited number of large cerebral arteriovenous malformations treated. Other strategies as fractioned irradiation, multileaf microcollimators with single isocenter, radiosurgery before surgery or radiosurgery with protons should improve obliteration rate.
大型脑动静脉畸形的治疗对栓塞、手术和放射外科而言都是一项挑战。本研究的目的是回顾放射外科治疗这些大型脑动静脉畸形的结果，并研究可改善治疗效果的最新方法。
在我们的病例系列中，112例患者在接受放射外科治疗时脑动静脉畸形直径大于30毫米或体积大于10立方厘米。症状表现方式为：47%为出血，42%为癫痫发作，16%为头痛，7%为进行性神经功能缺损。2.7%的病例为偶然发现。在接受放射外科治疗前，57%的患者接受过栓塞治疗，5%接受过手术，4.5%接受过再次放疗，1.8%接受过手术及栓塞治疗。根据斯佩茨勒和马丁分级的分布情况如下：I级为0%，II级为12%，III级为41%，IV级为46%。无V级患者。
大型脑动静脉畸形的总体闭塞率为39%。在多变量分析中，只有恢复情况（正相关）和先前的栓塞治疗（负相关）与闭塞率相关。
目前的放射外科治疗方法只能使部分接受治疗的大型脑动静脉畸形实现闭塞。其他策略，如分次照射、单等中心多叶微型准直器、术前放射外科或质子放射外科，应能提高闭塞率。
