Inoue Tomoo, Endo Toshiki, Takai Keisuke, Seki Toshitaka
Department of Neurosurgery, Saitama Red Cross Hospital, Saitama , Japan.
Department of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai , Japan.
Neurosurgery. 2025 Apr 14;97(3):691-699. doi: 10.1227/neu.0000000000003444.
Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) presenting with subarachnoid hemorrhage (SAH) are rare conditions, with the optimal timing and approach to treatment still debated among neurosurgeons. The aim of this study was to characterize CCJ AVF-related SAH and determine appropriate surgical timing in a multicenter study.
Data from 111 consecutive patients with CCJ AVF, including 51 with SAH, were collected from 29 centers across Japan. The vascular anatomy, diagnosis, treatment, surgical timing, and clinical outcomes were analyzed. Binary logistic regression was used to identify risk factors for complications.
The mean age of the patients was 67 years (range, 33-85 years), with 36 male patients and 15 female patients. Notably, a high percentage of patients (84%) presented with mild SAH (World Federation of Neurosurgical Societies grade I or II). Rebleeding and symptomatic vasospasm each occurred in 2% of cases. Initial treatments included direct surgery (n = 38), endovascular treatment (n = 10), and combined therapy (n = 3). Of the 51 patients, 17.6% (9/51) underwent acute (within 3 days of onset), 17.6% (9/51) subacute (within 4-14 days), and 64.7% (33/51) delayed procedures (after 15 days). Our study revealed a higher rate of complications, especially ischemic complications ( P = .028), in patients who underwent acute surgery than in those who underwent delayed procedures. Endovascular treatment required retreatment in 60% (6/10) of cases, whereas direct surgery did not necessitate retreatment. The final modified Rankin Scale scores did not differ based on surgical timing.
CCJ AVF-related SAH is often mild, as evidenced by a high proportion of patients with low-grade World Federation of Neurosurgical Societies scores and a low rate of rebleeding/vasospasm. In contrast to intracranial aneurysmal SAH, our results do not support acute surgical intervention as the preferred management for patients with CCJ AVF-related SAH. Through delayed surgery, clinicians can avoid ischemic complications and improve patient outcomes.
颅颈交界区（CCJ）动静脉瘘（AVF）合并蛛网膜下腔出血（SAH）是一种罕见疾病，神经外科医生对于其最佳治疗时机和方法仍存在争议。本研究的目的是在一项多中心研究中对CCJ AVF相关的SAH进行特征描述，并确定合适的手术时机。
从日本29个中心收集了111例连续的CCJ AVF患者的数据，其中51例合并SAH。对血管解剖、诊断、治疗、手术时机和临床结果进行了分析。采用二元逻辑回归分析确定并发症的危险因素。
患者的平均年龄为67岁（范围33 - 85岁），男性36例，女性15例。值得注意的是，高比例患者（84%）表现为轻度SAH（世界神经外科协会联合会分级I或II级）。再出血和症状性血管痉挛的发生率均为2%。初始治疗包括直接手术（n = 38）、血管内治疗（n = 10）和联合治疗（n = 3）。在51例患者中，17.6%（9/51）接受了急性期（发病3天内）手术，17.6%（9/51）接受了亚急性期（4 - 14天内）手术，64.7%（33/51）接受了延迟手术（15天后）。我们的研究显示，与接受延迟手术的患者相比，接受急性期手术的患者并发症发生率更高，尤其是缺血性并发症（P = .028）。血管内治疗60%（6/10）的病例需要再次治疗，而直接手术无需再次治疗。最终改良Rankin量表评分在手术时机方面没有差异。
CCJ AVF相关的SAH通常较轻，低分级世界神经外科协会联合会评分的高比例患者以及再出血/血管痉挛的低发生率证明了这一点。与颅内动脉瘤性SAH不同，我们的结果不支持将急性手术干预作为CCJ AVF相关SAH患者的首选治疗方法。通过延迟手术，临床医生可以避免缺血性并发症并改善患者预后。
