Thompson R C, Steinberg G K, Levy R P, Marks M P
Department of Neurosurgery, Stanford University Medical Center, California 94305-5327, USA.
Neurosurgery. 1998 Aug;43(2):202-11; discussion 211-2. doi: 10.1097/00006123-199808000-00006.
Few published studies have focused specifically on the unique management issues encountered in treating patients with arteriovenous malformations (AVMs) and associated intracranial aneurysms. The primary objective of this study was to retrospectively review the clinical and radiographic features of these patients.
Medical records of all patients seen at Stanford University Hospital between 1988 and 1996 with a diagnosis of AVMs were retrospectively reviewed. Aneurysms were identified by conventional angiography and characterized by size, number, and location relative to the AVMs. AVMs were graded according to the Spetzler-Martin scale. Odds ratios were calculated for the risk of intracranial hemorrhage. Variables included age, sex, number of aneurysms, and AVM grade.
Forty-five of 600 patients (7.5%) were identified as having coexisting intracranial aneurysms. All 45 patients had high-flow malformations, and 58% had AVMs of Spetzler-Martin Grade IV or higher. A majority of patients had multiple aneurysms. There was a statistically significant increase in AVM hemorrhage in female patients (odds ratio, 8.53 [1.87-38.98]; P < 0.005). There was no statistically significant correlation between the development of hemorrhage and either age, AVM grade, or the number of aneurysms. Twenty-three patients (51%) presented with intracranial hemorrhage: bleeding occurred from the AVMs in 15 and from ruptured aneurysms in 5, and the source of the bleeding could not be determined in 3. Overall, nine patients (20%) bled from ruptured aneurysms: five at presentation, two during or within 3 weeks of AVM treatment, and two from new aneurysms. Two of these nine patients died as a direct result of aneurysmal subarachnoid hemorrhage. Five patients (11%) developed new aneurysms.
Aneurysms associated with AVMs are at risk for rupture before, during, and immediately after treatment of the AVMs. New aneurysms may arise in patients with high-flow AVMs. The risk of intracranial hemorrhage from either source is higher in female patients. To reduce the complications of intracranial hemorrhage in these patients, we recommend a management protocol designed to treat the aneurysms by surgical or endovascular means before administering definitive therapy for the AVMs. Meticulous intraoperative blood pressure control and fluid management during aneurysm surgery is critical to avoid hemorrhage from the AVMs.
很少有已发表的研究专门关注治疗动静脉畸形（AVM）及相关颅内动脉瘤患者时遇到的独特管理问题。本研究的主要目的是回顾性分析这些患者的临床和影像学特征。
回顾性分析1988年至1996年间在斯坦福大学医院就诊且诊断为AVM的所有患者的病历。通过传统血管造影识别动脉瘤，并根据其大小、数量以及相对于AVM的位置进行特征描述。AVM根据斯佩茨勒 - 马丁量表进行分级。计算颅内出血风险的比值比。变量包括年龄、性别、动脉瘤数量和AVM分级。
600例患者中有45例（7.5%）被确定存在颅内动脉瘤并存。所有45例患者均有高流量畸形，58%的患者AVM为斯佩茨勒 - 马丁IV级或更高。大多数患者有多个动脉瘤。女性患者的AVM出血有统计学显著增加（比值比，8.53 [1.87 - 38.98]；P < 0.005）。出血的发生与年龄、AVM分级或动脉瘤数量之间无统计学显著相关性。23例患者（51%）出现颅内出血：15例出血来自AVM，5例来自破裂动脉瘤，3例出血来源无法确定。总体而言，9例患者（20%）因动脉瘤破裂出血：5例在就诊时，2例在AVM治疗期间或治疗后3周内，2例来自新发动脉瘤。这9例患者中有2例因动脉瘤性蛛网膜下腔出血直接死亡。5例患者（11%）出现新发动脉瘤。
与AVM相关的动脉瘤在AVM治疗前、治疗期间及治疗后即刻均有破裂风险。高流量AVM患者可能会出现新发动脉瘤。女性患者来自任何一种来源的颅内出血风险更高。为减少这些患者颅内出血的并发症，我们建议采用一种管理方案，即在对AVM进行确定性治疗之前，通过手术或血管内手段治疗动脉瘤。动脉瘤手术期间严格控制术中血压和液体管理对于避免AVM出血至关重要。
