Kader A, Goodrich J T, Sonstein W J, Stein B M, Carmel P W, Michelsen W J
Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.
J Neurosurg. 1996 Jul;85(1):14-8. doi: 10.3171/jns.1996.85.1.0014.
Angiography has been considered to be the gold standard to judge the success of treatment for cerebral arteriovenous malformations (AVMs). Patients without residual nidus or early draining veins on postoperative angiograms are considered cured, with the risk of hemorrhage eliminated. A series of five patients with recurrent AVMs after negative postoperative angiography is described. All patients had hemispheric AVMs, presented initially with hemorrhage, and were between 5 and 13 years of age. Recurrence was noted 1 to 9 years later (at 12-16 years of age); after a hemorrhage in three patients, seizures in one, and on follow-up magnetic resonance imaging in one. Four patients underwent angiography that showed recurrence of the AVM at or adjacent to the original site. Three years postsurgery, the fifth patient died from a large intracerebral and intraventricular hemorrhage originating in the previous location of the AVM; however, the patient did not undergo angiography at the time of recurrence. The initial negative angiograms obtained postoperatively in these patients may be explained by postoperative spasm or thrombosis of a small residual malformation. However, in the authors' cumulative experience with 808 patients who have undergone complete surgical removal of AVMs (of whom 667 were older than 18 years of age), no case of recurrent AVM has been observed in an adult. Therefore, actual regrowth of an AVM may occur in children and could be a consequence of their relatively immature cerebral vasculature and may involve active angiogenesis mediated by humoral factors. The present findings argue against the assumption that AVMs are strictly congenital lesions resulting from failure of capillary formation during early embryogenesis. It is concluded that delayed imaging studies should be considered in children at least 1 year after their initial negative postoperative arteriogram to exclude a recurrent AVM.
血管造影术一直被认为是判断脑动静脉畸形（AVM）治疗是否成功的金标准。术后血管造影显示无残留病灶或早期引流静脉的患者被视为治愈，出血风险消除。本文描述了5例术后血管造影呈阴性但AVM复发的患者。所有患者均为半球型AVM，最初表现为出血，年龄在5至13岁之间。复发发生在1至9年后（年龄为12至16岁）；3例患者复发前有出血，1例有癫痫发作，1例通过随访磁共振成像发现复发。4例患者接受血管造影，显示AVM在原部位或其附近复发。术后3年，第5例患者死于源于先前AVM部位的大面积脑内和脑室内出血；然而，该患者复发时未进行血管造影。这些患者术后最初血管造影呈阴性可能是由于术后小的残留畸形发生痉挛或血栓形成。然而，根据作者对808例接受AVM完全手术切除患者（其中667例年龄大于18岁）的累积经验，未观察到成年患者有AVM复发的病例。因此，AVM实际再生长可能发生在儿童中，这可能是由于他们相对不成熟的脑血管系统所致，可能涉及体液因子介导的活跃血管生成。目前的研究结果反对AVM是早期胚胎发育过程中毛细血管形成失败导致的严格先天性病变这一假设。结论是，对于术后最初血管造影呈阴性的儿童，至少在术后1年应考虑进行延迟影像学检查，以排除AVM复发。
