特殊部位及类型脑动静脉畸形的临床特点及治疗

发布时间：2018-04-28 22:00

本文选题：回顾性研究 + 颅内出血　；参考：《南方医科大学》2017年博士论文

【摘要】：第一部分(第二章)后颅窝脑动静脉畸形的临床特点及辅助性血管内栓塞的临床疗效分析背景:后颅窝脑动静脉畸形(Posterior fossa brain arteriovenous malformations,PFbAVMs)是一种少见畸形,且具有高出血风险。而辅助性血管内栓塞该类畸形,可能有助于改善患者预后。方法:回顾性分析63例(14.1%)PFbAVM患者的临床特点及治疗结果,再出血率、畸形消除率以及改良的mRS(modified Rankin scale,mRS)评分用来评价临床疗效。结果:54例(85.7%)表现出血。多因素分析深静脉引流(P=0.012)及小脑(P=0.007)为出血危险因素。20例(31.7%)接受血管内栓塞,畸形平均消除率为46.9%。随访后有12例(67%)畸形团完全消失,2例(5.7%)发生永久性神经功能障碍,1例3年后再出血(再出血率4.6%)。对比术前mRS评分(P=0.039),20例行辅助性血管内栓塞的PFbAVMs预后良好(mRS≤2)。结论:小脑及深静脉引流为PFbAVMs的出血危险因素,辅助性血管内栓塞治疗PFbAVMs一种安全及有效的方法。第二部分(第三章)脑动静脉畸形的责任特征与相关性动脉瘤形成的研究背景:相关性动脉瘤(Associated Aneurysm,AA)形成与bAVMs的基本特征认识仍不足。方法:分析1999-2013收入我院的bAVMs合并AA患者的基本特征,并采用复发AA及畸形团残留大小评估bAVMs合并AA的临床结果。同时,ROC曲线衡量畸形团残留大小与复发AA的关系。结果:50/472例(15.0%)患者为bAVMs合并AA。该类畸形出血风险是单纯bAVMs的2倍。多因素logistic回归分析显示幕下畸形团(P0.001)以及瘘口(P=0.002)为AA形成的危险因素。平均随访22.7个月,具有幕下畸形团或者瘘口特征的bAVMs合并AA的患者治疗后,2例发生AA复发,其AA平均复发率为17.6%(7.2%在50例患者内)。ROC曲线显示具有幕下畸形团或者瘘口特征的bAVMs合并AA患者,其残留畸形团体积与AA的复发相关(P=0.023)。结论:bAVMs的幕下畸形团或瘘口是AA形成的危险因素,而畸形团体积减少80%以上,可预防AA复发并降低再出血风险。第三部分(第四章)综合性治疗未破裂脑动静脉畸形相关性头痛的临床研究背景:未破裂bAVMs合并症状性头痛(Symptomatic Headache,SH)较常见,但综合性治疗未破裂bAVMs是否缓解SH,未见相关报道。方法:分析综合性治疗未破裂bAVMs患者的SH特征及其缓解情况,探讨其自然病史;采用11级疼痛评分评估SH术前、中、后情况,而死亡或卒中及不良结果(modified Rankin Scale,mRS≥2)用于衡量该类畸形的自然病史。结果:23/41例(56.1%)偏头痛样头痛患者的畸形团位于枕叶(P0.001);40/63例(63.5%)紧张性头痛样头痛患者的畸形团位于额颞叶(P0.001)。综合治疗组在治疗紧张性头痛样头痛(87.8%)及所有类型的头痛(85.7%),SH缓解情况好于药物治疗组(31.8%,P0.001;40.7%,P0.001)。在死亡及卒中风险上,综合性治疗组与药物性治疗组无差异(P=0.393),而综合性治疗组(23.0%)在不良结果(mRS≥2)发生风险上较药物组(10.0%,P=0.022)高。结论:未破裂的枕叶bAVMs更趋表现为偏头痛样头痛,而未破裂的额颞叶bAVMs更趋表现为紧张性头痛样头痛。综合性治疗未破裂bAVMs有助于缓解或解除畸形相关的SH,但对于未破裂bAVMs的自然病史仍未明。
[Abstract]:The first part (chapter second) the clinical characteristics of the cerebral arteriovenous malformation in the posterior cranial fossa and the clinical efficacy of auxiliary intravascular embolization: the posterior cranial fossa cerebral arteriovenous malformation (Posterior fossa brain arteriovenous malformations, PFbAVMs) is a rare malformation with high bleeding risk. Help to improve the prognosis of patients. Methods: retrospective analysis of 63 cases (14.1%) PFbAVM patients' clinical characteristics and treatment results, rebleeding rate, deformity elimination rate and improved mRS (modified Rankin scale, mRS) score used to evaluate the clinical efficacy. Results: 54 cases (85.7%) appear bleeding. Multifactor analysis of deep venous drainage (P=0.012) and cerebellum (P=0.007) .20 cases (31.7%) received intravascular embolization for hemorrhagic risk factors. The average elimination rate of malformation was 12 cases (67%) after 46.9%. follow-up. 2 cases (5.7%) had permanent nerve dysfunction, 1 cases were rebleeding after 3 years (4.6%). Compared with preoperative mRS score (P=0.039), 20 patients with PFbAVMs had good prognosis. MRS < 2). Conclusion: cerebellar and deep venous drainage is a risk factor for hemorrhage of PFbAVMs. Adjuvant endovascular embolization is a safe and effective method for the treatment of PFbAVMs. The second part (third chapter) the responsibility characteristics of cerebral arteriovenous malformation and the research background of the formation of associated aneurysm: the formation of Associated Aneurysm (AA) and bAVMs The basic characteristics of the basic features were still insufficient. Methods: the basic characteristics of the patients with bAVMs combined with AA in our hospital were analyzed in 1999-2013, and the clinical results of bAVMs combined with AA were evaluated by the recurrence AA and the residual size of the malformed group. At the same time, the ROC curve was used to measure the relationship between the residual size of the malformed group and the recurrent AA. Results: 50/472 cases (15%) patients were bAVMs combined AA. such deformities. The risk of bleeding was 2 times of simple bAVMs. Multiple factor Logistic regression analysis showed that the sub episodes (P0.001) and the fistula (P=0.002) were the risk factors for AA formation. After 22.7 months of average follow-up, 2 cases of AA recurred after the treatment with bAVMs with the characteristics of the lower episodes or fistula, and the average recurrence rate of AA was 17.6% (7.2% in 50 cases). In patients) the.ROC curve showed that the bAVMs combined with AA with the characteristics of the lower episodic malformation or fistula was associated with the recurrence of AA (P=0.023). Conclusion: the sub episodic malformation or fistula of bAVMs is a risk factor for the formation of AA, and the volume of the malformed group decreases by more than 80%, which can prevent the recurrence of AA and reduce the risk of rebleeding. (third). The fourth chapter) the clinical research background of comprehensive treatment of unruptured cerebral arteriovenous malformation associated headache: Unruptured bAVMs with symptomatic headache (Symptomatic Headache, SH) is more common, but the comprehensive treatment of unruptured bAVMs to alleviate SH is not reported. Methods: analysis of the comprehensive treatment of unruptured bAVMs patients with SH characteristics and remission situation A 11 grade pain score was used to assess the natural history of SH before, middle and posterior, and death or stroke and bad results (modified Rankin Scale, mRS > 2) used to measure the natural history of this kind of deformity. Results: 23/41 cases (56.1%) migraine like headache patients were located in the occipital lobe (P0.001); 40/63 (63.5%) tension headache like head The malformed group in the pain patients was located in the frontal and temporal lobe (P0.001). The comprehensive treatment group was treated for tension headache like headache (87.8%) and all types of headache (85.7%), and the remission of SH was better than that of the drug treatment group (31.8%, P0.001; 40.7%, P0.001). There was no difference between the comprehensive treatment group and the drug treatment group (P=0.393) in the risk of death and stroke (P=0.393), and the comprehensive treatment was used. Group (23%) was higher in the risk of adverse outcome (mRS > 2) than in the drug group (10%, P=0.022). Conclusion: the unruptured bAVMs of the occipital lobe is more likely to be a migraine like headache, while the unruptured bAVMs is more likely to be a tension headache like headache. Comprehensive treatment of unruptured bAVMs helps to relieve or relieve the malformed SH, but it is not broken. The natural history of bAVMs is still unknown.

【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R651.12

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