Baharvahdat H, Blanc R, Termechi R, Pistocchi S, Bartolini B, Redjem H, Piotin M
From the Department of Interventional Neuroradiology (H.B., R.B., S.P., B.B., H.R., M.P.), Fondation Adolphe de Rothschild, Paris, FranceNeurosurgical Department (H.B.), Ghaem Hospital, Mashhad University of Medical Sciences, Iran.
From the Department of Interventional Neuroradiology (H.B., R.B., S.P., B.B., H.R., M.P.), Fondation Adolphe de Rothschild, Paris, France
AJNR Am J Neuroradiol. 2014 May;35(5):978-83. doi: 10.3174/ajnr.A3906. Epub 2014 Mar 27.
Intracranial hemorrhage is the most severe complication of brain arteriovenous malformation treatment. We report our rate of hemorrhagic complications after endovascular treatment and analyze the clinical significance and potential mechanisms, with emphasis on cases of delayed hemorrhage after uneventful embolization.
During a 10-year period, 846 embolization procedures were performed in 408 patients with brain AVMs. Any cases of hemorrhagic complications were identified and divided into those related or unrelated to a periprocedural arterial tear (during catheter navigation or catheter retrieval). We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM, number of embolized pedicles, microcatheter used, type and volume of liquid embolic agent injected, and the presence of a premature venous occlusion. Univariate and multivariate multiple regression analyses were performed to identify risk factors for hemorrhagic complications.
A hemorrhagic complication occurred in 92 (11%) procedures. Forty-four (48%) complications were related to a periprocedural arterial perforation, and 48 (52%) were not. Hemorrhagic complications unrelated to an arterial perforation were located more commonly in the cerebral parenchyma, caused more neurologic deficits, and were associated with worse prognosis than those in the arterial perforation group. Only premature venous occlusion was identified as an independent predictor of hemorrhagic complication in the nonperforation group. Premature venous occlusion was significantly related to the ratio of Onyx volume to nidus diameter.
Higher injected volume of embolic agent and deposition on the venous outflow before complete occlusion of the AVM may account for severe hemorrhagic complications.
颅内出血是脑动静脉畸形治疗最严重的并发症。我们报告血管内治疗后出血性并发症的发生率，并分析其临床意义及潜在机制，重点关注栓塞过程顺利后发生的延迟性出血病例。
在10年期间，对408例脑动静脉畸形患者进行了846次栓塞手术。确定所有出血性并发症病例，并分为与围手术期动脉撕裂相关（导管导航或导管取出期间）或无关的病例。我们分析了以下变量：性别、年龄、出血表现、Spetzler-Martin分级、动静脉畸形大小、栓塞蒂数量、使用的微导管、注入的液体栓塞剂类型和体积，以及是否存在过早静脉闭塞。进行单因素和多因素多元回归分析以确定出血性并发症的危险因素。
92例（11%）手术发生出血性并发症。44例（48%）并发症与围手术期动脉穿孔相关，48例（52%）无关。与动脉穿孔无关的出血性并发症更常见于脑实质，导致更多神经功能缺损，且与动脉穿孔组相比预后更差。在非穿孔组中，仅过早静脉闭塞被确定为出血性并发症的独立预测因素。过早静脉闭塞与Onyx体积与病灶直径之比显著相关。
栓塞剂注入量较高以及在动静脉畸形完全闭塞前沉积在静脉流出道可能是严重出血性并发症的原因。
