Beaty Narlin B, Campos Jessica K, Colby Geoffrey P, Lin Li-Mei, Bender Matthew T, Xu Risheng, Coon Alexander L
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Interv Neurol. 2018 Apr;7(3-4):164-170. doi: 10.1159/000484986. Epub 2018 Feb 3.
An estimated 0.1% of the population harbors brain arteriovenous malformations (AVMs). Diagnosis and workup of AVMs include thorough evaluation for characterization of AVM angioarchitecture and careful assessment for concomitant aneurysms. The presence of coexisting aneurysms is associated with an increased risk of intracranial hemorrhage, with a published risk of 7% per year compared to patients with AVMs alone with a risk of 3%. Comprehensive AVM management requires recognition of concomitant aneurysms and prioritizes treatment strategies to mitigate the aggregate risk of intracranial hemorrhage associated with AVM rupture in patients with coexisting aneurysms. Endovascular treatment of these flow-related aneurysms can offer a cure, while avoiding open surgery. Successful flow-diverting embolization techniques, efficacy, and outcomes have been previously described for a variety of aneurysm types and locations. However, use of a flow diverter has not been previously described for the treatment of high-flow aneurysms on AVM-feeding vessels.
We report 2 cases of large AVMs within eloquent cortex associated with flow-related aneurysms in patients presenting initially with suspected intracerebral hemorrhage secondary to AVM rupture.
No consensus currently exists to guide treatment of intracranial aneurysms associated with AVMs. Surgical management addressed AVM embolization initially, as the vasculopathology with the highest rupture risk. Subsequently, Pipeline embolization of the associated aneurysms with adequate antiplatelet treatment was performed before scheduled radiosurgery to decrease the risk of AVM rupture or rebleed. This represents a novel and promising use of the Pipeline Embolization Device. Additional cases and longer follow-up will be needed to further assess the efficacy of this technique.
据估计，0.1%的人口患有脑动静脉畸形（AVM）。AVM的诊断和检查包括对AVM血管结构特征的全面评估以及对伴随动脉瘤的仔细评估。并存动脉瘤的存在与颅内出血风险增加相关，已发表的每年风险为7%，而单纯AVM患者的风险为3%。全面的AVM管理需要识别并存的动脉瘤，并优先考虑治疗策略，以降低并存动脉瘤患者中与AVM破裂相关的颅内出血总风险。这些血流相关动脉瘤的血管内治疗可以治愈，同时避免开颅手术。先前已描述了针对各种动脉瘤类型和位置的成功的血流导向栓塞技术、疗效和结果。然而，此前尚未描述使用血流导向装置治疗AVM供血血管上的高流量动脉瘤。
我们报告了2例位于功能区皮质内的大型AVM病例，这些病例与最初表现为疑似AVM破裂继发脑出血的患者的血流相关动脉瘤有关。
目前尚无共识指导与AVM相关的颅内动脉瘤的治疗。手术管理最初针对AVM栓塞，因为这是破裂风险最高的血管病变。随后，在预定的放射外科手术前，对相关动脉瘤进行Pipeline栓塞并给予充分的抗血小板治疗，以降低AVM破裂或再出血的风险。这代表了Pipeline栓塞装置的一种新颖且有前景的应用。需要更多病例和更长时间的随访来进一步评估该技术的疗效。
