Hartmann A, Mast H, Mohr J P, Koennecke H C, Osipov A, Pile-Spellman J, Duong D H, Young W L
Stroke Unit, The Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY 10032, USA.
Stroke. 1998 May;29(5):931-4. doi: 10.1161/01.str.29.5.931.
Decisions on invasive arteriovenous malformation (AVM) treatment are currently based on natural-course risk estimates of AVM bleeding and assumptions on morbidity from cerebral hemorrhage in general. However, morbidity of AVM hemorrhage has rarely been reported. We sought to assess the morbidity of intracranial hemorrhage in patients with cerebral AVMs.
From a prospective AVM database, 119 patients were analyzed: 115 had a hemorrhage as the diagnostic event, and 27 of them suffered a second hemorrhage during follow-up; an additional 4 patients had other diagnostic symptoms but bled during follow-up. The type (parenchymal, subarachnoid, intraventricular) and location of AVM hemorrhage were determined by CT/MR brain imaging. Disability and neurological impairment were assessed with the Barthel Index, the Rankin Scale, and the National Institutes of Health Stroke Scale, with a mean follow-up time of 16.2 months.
Of the 115 incident hemorrhages, 34 (30%) were subarachnoid, 27 (23%) parenchymal, 18 (16%) intraventricular, and 36 (31%) in combined locations. In 54 patients (47%; 95% confidence interval [CI], 38% to 56%) the incident hemorrhage resulted in no neurological deficit, and an additional 43 patients (37%; 95% CI, 28% to 46%) were independent in their daily activities (Rankin 1). Fifteen patients (13%; 95% CI, 7% to 19%) were moderately disabled (Rankin 2 or 3), and 3 (3%; 95% CI, 0% to 6%) were severely disabled (Rankin > or =4). Parenchymal hemorrhages were most likely to result in a neurological deficit (52%). Type and morbidity of hemorrhage during follow-up were similar to incident events. Twenty (74%) of 27 patients with both incident and follow-up hemorrhages were normal or independent (Rankin 0 or 1). None of the patients with a hemorrhage during follow-up died during the observation period.
Hemorrhage from cerebral AVMs appears to have a lower morbidity than currently assumed. This finding encourages a reevaluation of the risks and benefits of invasive AVM treatment.
目前，侵袭性动静脉畸形（AVM）治疗决策基于AVM出血的自然病程风险估计以及一般脑出血发病率的假设。然而，AVM出血的发病率鲜有报道。我们旨在评估脑AVM患者颅内出血的发病率。
从一个前瞻性AVM数据库中分析了119例患者：115例以出血作为诊断事件，其中27例在随访期间发生二次出血；另外4例有其他诊断症状但在随访期间出血。通过脑部CT/MR成像确定AVM出血的类型（实质内、蛛网膜下腔、脑室内）和部位。采用Barthel指数、Rankin量表和美国国立卫生研究院卒中量表评估残疾和神经功能缺损情况，平均随访时间为16.2个月。
在115例首次出血中，34例（30%）为蛛网膜下腔出血，27例（23%）为实质内出血，18例（16%）为脑室内出血，36例（31%）为联合部位出血。54例患者（47%；95%置信区间[CI]，38%至56%）首次出血未导致神经功能缺损，另外43例患者（37%；95%CI，28%至46%）日常生活自理（Rankin 1级）。15例患者（13%；95%CI，7%至19%）中度残疾（Rankin 2或3级），3例患者（3%；95%CI，0%至6%）重度残疾（Rankin≥4级）。实质内出血最易导致神经功能缺损（52%）。随访期间出血的类型和发病率与首次事件相似。27例有首次和随访出血的患者中，20例（74%）正常或自理（Rankin 0或1级）。随访期间出血的患者在观察期内均未死亡。
脑AVM出血的发病率似乎低于目前的假设。这一发现促使重新评估侵袭性AVM治疗的风险和益处。
