Maruyama Keisuke, Shin Masahiro, Tago Masao, Kurita Hiroki, Kawahara Nobutaka, Morita Akio, Saito Nobuhito
Department of Neurosurgery and Radiology, The University of Tokyo Hospital, Tokyo, Japan.
J Neurosurg. 2006 Dec;105 Suppl:52-7. doi: 10.3171/sup.2006.105.7.52.
Appropriate management of hemorrhage after Gamma Knife surgery (GKS) for arteriovenous malformations (AVMs) of the brain is poorly understood, although a certain proportion of patients suffer from hemorrhage.
Among 500 patients observed for 1 to 183 months (median 70 months) after GKS, 32 patients (6.4%) suffered a hemorrhage. Hemorrhage developed even after angiographically documented obliteration of the AVM in five (2%) of 250 patients followed for 1 to 133 months (median 75 months) post-GKS. These patients had been treated according to their pathological condition. Treatment of these patients and their outcomes were retrospectively reviewed. As a management strategy in patients with preobliteration hemorrhage, the intracerebral hematoma and the AVM nidus were removed in four patients, and chronic encapsulated hematoma was removed in three. Among 11 patients who were conservatively treated, AVMs were ultimately obliterated in five, including three patients who underwent repeated GKS. Intracerebral hematoma from angiographically documented obliterated AVMs was radically resected in two patients, including one who also underwent aspiration of an accompanying symptomatic cyst. Intraoperative bleeding was easily controlled in these patients. Outcomes after hemorrhage, measured with the modified Rankin Scale, were significantly better in patients with postobliteration hemorrhage than in those with preobliteration hemorrhage (p < 0.05).
Various types of hemorrhagic complications after GKS for AVMs can be properly managed based on an understanding of each pathological condition. Although a small risk of bleeding remains after angiographically demonstrated obliteration, surgery for such AVMs is safe, and the patient outcomes are more favorable. Radical resection to prevent further hemorrhage is recommended for ruptured AVMs after obliteration because such AVMs can cause repeated hemorrhages.
尽管一定比例的脑动静脉畸形（AVM）患者在伽玛刀手术（GKS）后会发生出血，但对于GKS术后出血的恰当处理仍了解不足。
在500例接受GKS术后观察1至183个月（中位时间70个月）的患者中，32例（6.4%）发生了出血。在GKS术后1至133个月（中位时间75个月）随访的250例患者中，有5例（2%）在血管造影证实AVM闭塞后仍发生了出血。这些患者均根据其病情接受了治疗。对这些患者的治疗及预后进行了回顾性分析。作为对闭塞前出血患者的处理策略，4例患者清除了脑内血肿和AVM病灶，3例患者清除了慢性包裹性血肿。在11例接受保守治疗的患者中，最终有5例AVM闭塞，其中3例接受了重复GKS治疗。2例血管造影证实已闭塞的AVM引起的脑内血肿被彻底切除，其中1例还对伴随的有症状囊肿进行了穿刺抽吸。这些患者术中出血易于控制。采用改良Rankin量表衡量，闭塞后出血患者的出血后预后明显优于闭塞前出血患者（p < 0.05）。
基于对每种病情的了解，GKS治疗AVM后出现的各种出血并发症能够得到恰当处理。尽管血管造影显示闭塞后仍有小出血风险，但此类AVM手术是安全的，且患者预后更佳。对于闭塞后破裂的AVM，建议进行根治性切除以防止再次出血，因为此类AVM可导致反复出血。
