Division of Interventional Neuroradiology, Department of Radiological Sciences, UCLA Medical Center and David Geffen School of Medicine, University of California, Los Angeles, California 90095-1721, USA.
J Neurosurg. 2010 Oct;113(4):715-22. doi: 10.3171/2009.9.JNS081588.
High-flow fistulas associated with brain arteriovenous malformations (AVMs) pose a significant challenge to both stereotactic radiosurgery (SRS) and surgical treatment. The purpose of this study was to examine the outcomes of multimodality treatment of AVMs in association with a large arteriovenous fistula (AVF), with a special focus on endovascular embolization and its associated complications.
One hundred ninety-two patients harboring cerebral AVMs underwent endovascular treatment in the authors' department between 1997 and 2003. Of these, the authors selected 74 patients presenting with an AVM associated with high-flow AVF(s) for a retrospective analysis based on the findings of superselective angiography. After endovascular embolization, 32 patients underwent resection, 33 underwent either SRS or hypofractionated stereotactic radiotherapy (HSRT), and 3 underwent both surgery and SRS. Six patients underwent embolization only. Immediate and midterm treatment outcomes were analyzed.
Fifty-seven (77%) of the 74 patients had AVMs that were Spetzler-Martin Grade III or higher. A complete resection was achieved in all 32 patients. Of patients who underwent SRS/HSRT, 13 patients (39.3%) had either complete or > 90% obliteration of the AVM, and 2 patients (6.1%) had incomplete obliteration. Fourteen patients (42.4%) with residual AVM underwent repeated radiotherapy (and remain under observation). Of the 3 patients who underwent both SRS and resection, resection was complete in 2 and incomplete in one. No follow-up was obtained in 6 patients (8.1%). An endovascular complication was observed in 4 patients (5.4%). Fistula embolization was safely performed in every patient, whereas every endovascular complication was associated with other procedures such as nidus embolization.
Endovascular occlusion of the fistulous component was successfully achieved in every patient; every endovascular complication in this series was related to other procedures such as nidus embolization. The importance of the fistula treatment should be emphasized to minimize the endovascular complications and to maximize the treatment effect when a multimodality therapy is used to treat brain AVMs with large AVF.
与脑动静脉畸形（AVM）相关的高流量瘘管给立体定向放射外科（SRS）和手术治疗带来了重大挑战。本研究旨在探讨伴有大动静脉瘘（AVF）的 AVM 多模态治疗的结果，特别关注血管内栓塞及其相关并发症。
1997 年至 2003 年，作者所在科室对 192 例脑 AVM 患者进行了血管内治疗。在此基础上，作者根据超选择性血管造影的发现，选择了 74 例伴有高流量 AVF 的 AVM 患者进行回顾性分析。血管内栓塞后，32 例患者行切除术，33 例患者行 SRS 或低分割立体定向放射治疗（HSRT），3 例患者行手术联合 SRS。6 例患者仅行栓塞治疗。分析即刻和中期治疗结果。
74 例患者中有 57 例（77%）AVM 为 Spetzler-Martin 分级Ⅲ级或更高。所有 32 例患者均行完全切除术。行 SRS/HSRT 的患者中，13 例（39.3%）AVM 完全或>90%闭塞，2 例（6.1%）不完全闭塞。14 例（42.4%）有残留 AVM 的患者接受了重复放疗（并仍在观察中）。3 例同时行 SRS 和切除术的患者中，2 例完全切除，1 例不完全切除。6 例（8.1%）患者未获得随访。4 例（5.4%）患者出现血管内并发症。每例患者均成功进行瘘管栓塞，而本系列中的每例血管内并发症均与血管内治疗（如病灶栓塞）相关。在使用多模态治疗伴有大 AVF 的脑 AVM 时，强调瘘管治疗的重要性，以最大限度地减少血管内并发症并最大限度地提高治疗效果。
