Iwama Toru, Yoshimura Kunikazu, Keller Emanuela, Imhof Hans-Georg, Khan Nadia, Leblebicioglu-Könu Dilek, Tanaka Michihiro, Valavanis Anton, Yonekawa Yasuhiro
Department of Neurosurgery and Institute of Neuroradiology, University Hospital Zürich, Zürich, Switzerland.
Neurosurgery. 2003 Dec;53(6):1251-8; discussion 1258-60. doi: 10.1227/01.neu.0000093198.98170.d4.
We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome.
Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score < or =6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively.
Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed.
In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.
我们试图评估幕上动静脉畸形（AVM）血管内栓塞术后继发大量血肿患者进行急诊开颅手术的疗效，并研究影响预后的相关因素。
在过去15年中，我院605例颅内AVM患者接受了1066次血管内栓塞治疗。其中，24例患者在治疗期间或治疗后发生颅内出血。14例患者被证实有大量脑实质内血肿并昏迷（格拉斯哥昏迷量表评分≤6分）。12例患者在被诊断为脑实质内出血后170分钟内接受了开颅手术。实施的手术包括AVM全切除（6例）或部分切除（2例）并行血肿清除术，或仅行血肿清除术（4例）。对这12例患者的临床记录进行回顾性分析。
9例患者恢复良好（4例恢复良好，5例中度残疾），1例患者持续处于植物状态，2例患者死亡。预后良好的患者出血与急诊开颅手术之间的间隔时间明显短于临床预后不良的患者。高龄和术中失血量较大是与预后不良相关的因素。AVM位于颞叶和栓塞不完全往往与临床预后不良相关，但这种相关性无统计学意义。AVM和血肿的大小与患者预后无关。所实施的手术方式在预后方面无差异。
对于栓塞术后大量血肿患者，应尽快进行急诊开颅手术以获得良好预后。介入神经放射科医生、重症监护医生和神经外科医生之间的合作对于治疗栓塞后严重出血的AVM患者至关重要。在急诊开颅手术时无需坚持同时完全切除AVM。
