de Souza Coelho Daniela, Fernandes de Oliveira Santos Bruno, Silva da Costa Marcos Devanir, Silva Gisele Sampaio, Cavalheiro Sergio, Santos Flávia H, Chaddad-Neto Feres
1Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil; and.
2School of Psychology, University College Dublin, Ireland.
J Neurosurg. 2019 Apr 12;132(5):1548-1555. doi: 10.3171/2018.12.JNS181883. Print 2020 May 1.
A cerebral arteriovenous malformation (cAVM) can change over time and cause symptoms, but clinical studies tend to define only the patients with ruptured cAVMs as symptomatic and do not consider neurocognitive aspects prior to neurosurgical intervention. The objective of this study was to describe the neurocognitive function of patients with ruptured and unruptured cAVMs according to the Spetzler-Martin (SM) grade, flow status, and anatomical topography.
In this blinded cross-sectional study, 70 patients of both sexes and ages 18-60 years were evaluated using the Brazilian Brief Neuropsychological Assessment Battery Neupsilin.
Of the 70 patients with cAVMs, 50 (71.4%) demonstrated deficits in at least one of the eight neurocognitive domains surveyed, although they did not exhibit neurological deficits. cAVMs in the temporal lobe were associated with memory deficits compared with the general population. The SM grade was not significantly associated with the results of patients with unruptured cAVMs. However, among patients with ruptured cAVMs, there were deficits in working memory in those with high-grade (SM grade) cAVMs and deficits in executive function (verbal fluency) in those with low-grade cAVMs (p < 0.001).
This study indicates that patients with untreated cAVMs, either ruptured or unruptured, already exhibit neurocognitive deficits, even the patients without other neurological symptoms. However, the scales used to evaluate disability in the main clinical studies, such as A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), do not assess neurocognitive alterations and therefore disregard any deficits that may affect quality of life. The authors' finding raises an important question about the effects of interventional treatment because it reinforces the hypothesis that cognitive alterations may be preexisting and not determined by interventions.
脑动静脉畸形（cAVM）会随时间变化并引发症状，但临床研究往往仅将破裂的cAVM患者定义为有症状，且在神经外科干预前未考虑神经认知方面。本研究的目的是根据斯佩茨勒 - 马丁（SM）分级、血流状态和解剖位置描述破裂和未破裂cAVM患者的神经认知功能。
在这项双盲横断面研究中，使用巴西简短神经心理评估量表Neupsilin对70名年龄在18至60岁的男女患者进行评估。
在70例cAVM患者中，50例（71.4%）在所调查的八个神经认知领域中至少有一个领域存在缺陷，尽管他们没有表现出神经功能缺损。与一般人群相比，颞叶的cAVM与记忆缺陷相关。SM分级与未破裂cAVM患者的结果无显著相关性。然而，在破裂cAVM患者中，高级别（SM分级）cAVM患者存在工作记忆缺陷，低级别cAVM患者存在执行功能（言语流畅性）缺陷（p < 0.001）。
本研究表明，未经治疗的破裂或未破裂cAVM患者即使没有其他神经症状，也已表现出神经认知缺陷。然而，主要临床研究中用于评估残疾的量表，如未破裂脑动静脉畸形随机试验（ARUBA），并未评估神经认知改变，因此忽略了任何可能影响生活质量的缺陷。作者的发现引发了一个关于介入治疗效果的重要问题，因为它强化了认知改变可能是预先存在而非由干预决定的这一假设。
