Stein Klaus-Peter, Wanke Isabel, Forsting Michael, Zhu Yuan, Moldovan Alexia Sabine, Dammann Phillipp, Sandalcioglu I Erol, Sure Ulrich
Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
Cerebrovasc Dis. 2015;39(2):122-9. doi: 10.1159/000369958. Epub 2015 Jan 31.
Associated aneurysms (AAs) are presumed to represent an additional risk factor for intracranial haemorrhage from cerebral arterio-venous malformations (AVMs). To date, efforts to capture their natural history, as well as to identify aneurysms with the potential capability of regression after AVM treatment remain incomprehensive. As the aneurysm size represents an important aspect for the treatment indication of incidental saccular aneurysms, this factor has rarely been encountered for the treatment of AAs so far. The present study aims to determine the angiographic and clinical characteristics of AAs with special focus on aneurysm size and their consequences for treatment.
Patients with cerebral AVMs, treated in our department between 1990 and 2013, were analyzed retrospectively. Only patients with supratentorial AVMs and flow-related AAs of the feeding arteries were evaluated. Thus, patients harboring AVMs of the cerebellum and the brain stem and patients with intranidal, venous or remote aneurysms were excluded. Treatment strategies were assessed with special attention on bleeding source and on AA size.
In 59 of 409 patients (14%) with supratentorial AVMs, a total of 85 AAs of the feeding arteries were identified. 14 of 59 individuals (24%) presented with multiple AAs. Of 85 AA, 58 aneurysms (68%) were classified as proximal and 27 aneurysms (32%) as distal. The most common location of AAs was the middle cerebral artery (MCA, 39%), followed by the internal carotid artery (ICA, 27%) and the anterior cerebral artery (ACA, 21%). The mean AA size was 4.4 mm ± 3.4 mm. Intracranial haemorrhage was found in 21 of 59 patients (36%) with coexisting AAs. Among these, 10 individuals (17%) suffered from rupture of an AA, accounting for nearly half of all bleedings in this subgroup. Among those patients bearing a single AA, the size of ruptured aneurysms differed significantly from those unruptured (6.6 mm vs. 4.4 mm, p = 0.0046). Nineteen patients (32%) received treatment of 22 AAs, whereas sole AVM treatment was adopted in 26 patients (44%) and conservative management in 14 patients (24%). The main reasons to leave AAs untreated were the small AA size (<5 mm), poor clinical state or treatment denial by the patients.
The aneurysm size of AAs in AVM influences the risk of haemorrhage. Therefore, the treatment of larger (diameter ≥5 mm) AAs should be considered, even if a treatment indication of the associated AVM is not given.
伴发动脉瘤（AAs）被认为是脑动静脉畸形（AVM）导致颅内出血的一个额外风险因素。迄今为止，对其自然病史的了解以及识别出在AVM治疗后具有可能发生消退的动脉瘤的努力仍不全面。由于动脉瘤大小是偶然发现的囊状动脉瘤治疗指征的一个重要方面，到目前为止，这一因素在AAs治疗中很少被考虑。本研究旨在确定AAs的血管造影和临床特征，特别关注动脉瘤大小及其对治疗的影响。
回顾性分析1990年至2013年在我科接受治疗的脑AVM患者。仅评估幕上AVM和供血动脉的血流相关AAs患者。因此，排除了患有小脑和脑干AVM的患者以及患有瘤内、静脉或远处动脉瘤的患者。评估治疗策略时特别关注出血源和AA大小。
在409例幕上AVM患者中的59例（14%）中，共识别出85个供血动脉的AAs。59例个体中有14例（24%）表现为多发AAs。在85个AAs中，58个动脉瘤（68%）被分类为近端，27个动脉瘤（32%）为远端。AAs最常见的位置是大脑中动脉（MCA，39%），其次是颈内动脉（ICA，27%）和大脑前动脉（ACA，21%）。AA的平均大小为4.4 mm±3.4 mm。在59例合并AAs的患者中，21例（36%）发生颅内出血。其中，10例个体（17%）因AA破裂出血，占该亚组所有出血的近一半。在那些仅患有单个AA的患者中，破裂动脉瘤的大小与未破裂的有显著差异（6.6 mm对4.4 mm，p = 0.0046）。19例患者（32%）接受了22个AAs的治疗，而26例患者（44%）仅接受了AVM治疗，14例患者（24%）采取了保守治疗。未治疗AAs的主要原因是AA尺寸小（<5 mm）、临床状态差或患者拒绝治疗。
AVM中AAs的动脉瘤大小影响出血风险。因此，即使相关AVM没有治疗指征，对于较大（直径≥5 mm）的AAs也应考虑治疗。
