Mansur Ann, Kostynskyy Alex, Krings Timo, Agid Ronit, Radovanovic Ivan, Mendes Pereira Vitor
1Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto.
2Division of Neuroradiology, Department of Medical Imaging, and.
J Neurosurg. 2021 May 7;135(6):1598-1607. doi: 10.3171/2020.9.JNS201558. Print 2021 Dec 1.
The aim of this study was to 1) compare the safety and efficacy of acute targeted embolization of angiographic weak points in ruptured brain arteriovenous malformations (bAVMs) versus delayed treatment, and 2) explore the angioarchitectural changes that follow this intervention.
The authors conducted a retrospective analysis of a prospectively acquired database of ruptured bAVMs. Three hundred sixteen patients with ruptured bAVMs who presented to the hospital within 48 hours of ictus were included in the analysis. The first analysis compared clinical and functional outcomes of acutely embolized patients to those with delayed management paradigms. The second analysis compared these outcomes of patients with acute embolization to those with angiographic targets who did not undergo acute embolization. Finally, a subset of 20 patients with immediate postembolization angiograms and follow-up angiograms within 6 weeks of treatment were studied to determine the angioarchitectural changes after acute targeted embolization. Kaplan-Meier curves for survival between the groups were devised. Multivariate logistical regression analysis was conducted.
There were three deaths (0.9%) and an overall rerupture rate of 4.8% per year. There was no statistical difference in demographic variables, mortality, and rerupture rate between patients with acute embolization and those with delayed management. Patients with acute embolization were more likely to present functionally worse (46.9% vs 69.8%, modified Rankin Scale score 0-2, p = 0.018) and to require an adjuvant therapy (71.9% vs 26.4%, p < 0.001). When comparing acutely embolized patients to those nonacutely embolized angiographic targets, there was a significant protective effect of acute targeted therapy on rerupture rate (annual risk 1.2% vs 4.3%, p = 0.025) and no difference in treatment complications. Differences in the survival curves for rerupture were statistically significant. Multivariate analyses significantly predicted lower rerupture in acute targeted treatment and higher rerupture in those with associated aneurysms, deep venous anatomy, and higher Spetzler-Martin grade. All patients with acute embolization experienced complete obliteration of the angiographic weak point with various degrees of resolution of the nidus; however, some had spontaneous recurrence of their bAVM, while others had spontaneous resolution over time. No patients developed new angiographic weak points.
This study demonstrates that acute targeted embolization of angiographic weak points, particularly aneurysms, is technically safe and protective in the early phase of recovery from ruptured bAVMs. Serial follow-up imaging is necessary to monitor the evolution of the nidus after targeted and definitive treatments. Larger prospective studies are needed to validate these findings.
本研究的目的是：1）比较破裂脑动静脉畸形（bAVM）急性靶向栓塞造影薄弱点与延迟治疗的安全性和有效性；2）探讨该干预后血管结构的变化。
作者对前瞻性收集的破裂bAVM数据库进行了回顾性分析。分析纳入了316例在发病48小时内入院的破裂bAVM患者。首次分析比较了急性栓塞患者与采用延迟治疗模式患者的临床和功能结局。第二次分析比较了急性栓塞患者与未接受急性栓塞的造影靶点患者的这些结局。最后，研究了20例在栓塞后立即进行血管造影且在治疗后6周内进行随访血管造影的患者亚组，以确定急性靶向栓塞后的血管结构变化。绘制了各组之间生存的Kaplan-Meier曲线。进行了多变量逻辑回归分析。
有3例死亡（0.9%），每年的总体再破裂率为4.8%。急性栓塞患者与延迟治疗患者在人口统计学变量、死亡率和再破裂率方面无统计学差异。急性栓塞患者功能较差的可能性更大（改良Rankin量表评分0 - 2分，46.9%对69.8%，p = 0.018），且需要辅助治疗的可能性更大（71.9%对26.4%，p < 0.001）。将急性栓塞患者与未急性栓塞的造影靶点患者进行比较时，急性靶向治疗对再破裂率有显著的保护作用（年风险1.2%对4.3%，p = 0.025），且治疗并发症无差异。再破裂生存曲线的差异具有统计学意义。多变量分析显著预测急性靶向治疗中再破裂率较低，而在伴有动脉瘤、深静脉解剖结构和较高Spetzler-Martin分级的患者中再破裂率较高。所有急性栓塞患者造影薄弱点均完全闭塞，畸形团有不同程度的消退；然而，一些患者的bAVM有自发复发，而另一些患者随着时间推移有自发消退。没有患者出现新的造影薄弱点。
本研究表明，造影薄弱点，尤其是动脉瘤的急性靶向栓塞在破裂bAVM恢复的早期阶段在技术上是安全的且具有保护作用。需要进行系列随访成像以监测靶向和确定性治疗后畸形团的演变。需要更大规模的前瞻性研究来验证这些发现。
