Pasqualin A, Scienza R, Cioffi F, Barone G, Benati A, Beltramello A, Da Pian R
Department of Neurosurgery, Verona City Hospital, Italy.
Neurosurgery. 1991 Sep;29(3):358-68. doi: 10.1097/00006123-199109000-00004.
Forty-nine patients with cerebral arteriovenous malformations (AVMs) were treated with preoperative embolization followed by resection using a microsurgical approach. In 27 patients, the AVM was located in an eloquent area; in 32 patients, the volume of the AVM was over 20 cm3. Preoperatively, flow-directed embolization was performed in 10 patients (28 procedures), selective embolization with threads was performed in 35 patients (46 procedures), and a combination of flow-directed and selective embolization was performed in 4 patients (12 procedures). The percentage of reduction of the AVM volume averaged 36% after embolization. Five minor complications (transient neurological deficits, in 2 cases associated with ischemic areas on the CT scan) were observed after embolization. The interval between the last embolization and surgery was as follows: within 10 days in 7 patients; between 11 and 20 days in 3 patients; between 21 and 30 days in 10 patients; between 31 and 60 days in 11 patients; and 2 months later in 18 patients. The efficacy of this combined treatment (embolization plus surgery) was evaluated by the incidence of hyperemic complications and the clinical outcome. Hyperemic complications occurred more frequently in patients with an AVM volume greater than 20 cm3. When compared with flow-directed embolization, selective embolization was linked with decreased bleeding during surgery; postoperatively, the incidence of cerebral edema was also lower. Clinical outcome was better after selective embolization, with no occurrence of major deficits and no mortality. When the percentage of reduction of the AVM volume after embolization was 40% or more, the incidence of intraoperative hyperemic complications was lower; moreover, new permanent deficits were never observed in patients with this volume reduction. A retrospective clinical comparison of two groups of patients with similar AVM volumes (greater than 20 cm3)--those given combined treatment (n = 32) versus those treated by direct surgery alone (n = 27)--showed that intraoperative bleeding appeared to decrease in patients treated by embolization; the incidence of postoperative hyperemic complications was not different in the two groups. New major deficits and deaths were less frequent in patients treated by embolization (P = 0.05 for the incidence of major deficits); postoperative epilepsy was also less common in these patients. In conclusion, combined treatment with selective preoperative embolization and direct surgery may help the neurosurgeon in the treatment of large, high-flow AVMs, reducing the risks connected with their surgical removal.
49例脑动静脉畸形（AVM）患者接受了术前栓塞治疗，随后采用显微外科手术方法进行切除。27例患者的AVM位于功能区；32例患者的AVM体积超过20 cm³。术前，10例患者（共28次操作）进行了血流导向栓塞，35例患者（共46次操作）进行了丝线选择性栓塞，4例患者（共12次操作）进行了血流导向与选择性栓塞联合治疗。栓塞后AVM体积平均缩小36%。栓塞后观察到5例轻微并发症（短暂性神经功能缺损，2例与CT扫描显示的缺血区域有关）。最后一次栓塞与手术之间的间隔时间如下：7例患者在10天内；3例患者在11至20天之间；10例患者在21至30天之间；11例患者在31至60天之间；18例患者在2个月后。通过充血性并发症的发生率和临床结果评估这种联合治疗（栓塞加手术）的疗效。AVM体积大于20 cm³的患者充血性并发症更频繁发生。与血流导向栓塞相比，选择性栓塞与手术中出血减少有关；术后脑水肿的发生率也较低。选择性栓塞后的临床结果更好，未出现严重神经功能缺损且无死亡病例。当栓塞后AVM体积缩小百分比达到40%或更高时，术中充血性并发症的发生率较低；此外，体积缩小达到此程度的患者从未观察到新的永久性神经功能缺损。对两组AVM体积相似（大于20 cm³）的患者进行回顾性临床比较——联合治疗组（n = 32）与单纯直接手术组（n = 27）——结果显示，栓塞治疗的患者术中出血似乎减少；两组术后充血性并发症的发生率无差异。栓塞治疗的患者新的严重神经功能缺损和死亡情况较少见（严重神经功能缺损发生率P = 0.05）；这些患者术后癫痫也较少见。总之，术前选择性栓塞与直接手术联合治疗可能有助于神经外科医生治疗大型、高流量AVM，降低与其手术切除相关的风险。
