THE INFLUENCE OF HEMODYNAMIC AND ANATOMIC FACTORS ON HEMORRHAGE FROM CEREBRAL ARTERIOVENOUS-MALFORMATIONS
THE INFLUENCE OF HEMODYNAMIC AND ANATOMIC FACTORS ON HEMORRHAGE FROM CEREBRAL ARTERIOVENOUS-MALFORMATIONS
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DOI：
10.1227/00006123-199405000-00003
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发表时间：
1994-05-01
期刊：
影响因子：
4.8
通讯作者：
SOLOMON, RA
中科院分区：
文献类型：
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作者：
KADER, A;YOUNG, WL;SOLOMON, RA
导致脑动静脉畸形（AVM）出血的生理和解剖异常仍不清楚。为了阐明哪些情况可能导致出血，我们检查了一大群患者（n = 449）中出血或非出血表现组的临床和生理指标。检查的变量包括 AVM 大小、静脉引流类型、经颅多普勒 (TCD) 速度、喂养平均动脉压 (FMAP) 和引流静脉压力。 TCD 和压力数据在任何治疗之前获得。就诊时的年龄（平均+/-标准差）为33+/-13岁，组间没有差异。小（小于或等于 2.5 cm）AVM 的患者比中（> 2.5 且小于或等于 5.0 cm；52%）或大（> 5.0 cm；50%）AVM 的患者更容易出现出血（90%）（P = 0.0001）。 94 例 AVM 中的 48 例 (51%) 进行深静脉引流的患者比进行浅静脉引流的患者 (73 例中的 24 例 [33%]) 更容易发生出血 (P = 0.0219)。即使在中型和大型幕上 AVM 亚组中，深部引流也是出血的预测因素 (P = 0.005)。各组之间的引流静脉压力（n = 18）没有差异（分别为 21 +/- 10 和 19 +/- 11 mm Hg；P = 0.7812）。出血组的 FMAP (n = 52) 高于非出血组（44 +/- 13 vs 34 +/- 10 mm Hg；P = 0.0007），但与病变大小（最大尺寸）的相关性较弱（y = -0.74x + 40；r = 0.09）。与 FMAP 不同，TCD 速度与最大尺寸密切相关（n = 76；y = 15x + 86；r = 0.55）。尽管出血组表现出较低的平均流速（94 +/- 40 与 114 +/- 33；P = 0.0236），但绝对差异很小，表明 TCD 指数与大小的相关性大于出血倾向。通过使用多元逻辑回归模型，在中型或大型 AVM 和浅静脉引流的患者亚组中（脑出血风险最低的组），FMAP 对脑出血的发生率有很大影响（P = 0.0086），但 TCD 速度则没有。总之，较小的病灶大小和深静脉引流的存在是可能增加动静脉畸形出血风险的独立预测因素。最后，较高的 FMAP 是 AVM 出血病理生理学的一个重要因素，而不仅仅是病变大小的结果。
THE PHYSIOLOGICAL AND anatomical aberrations that result in hemorrhage from cerebral arteriovenous malformations (AVMs) remain unclear. In an attempt to clarify which conditions may predispose, to hemorrhage, we examined clinical and physiological indices on presentation groups of either hemorrhage or nonhemorrhage in a large cohort of patients (n = 449). Variables examined included AVM size, type of venous drainage, transcranial Doppler (TCD) velocities, feeding mean arterial pressure (FMAP), and draining vein pressure. TCD and pressure data were obtained before any treatment. Age (mean +/- standard deviation) at the time of presentation was 33 +/- 13 years and did not differ between groups. Patients with small (less than or equal to 2.5 cm) AVMs presented more frequently with hemorrhage (90%) than did patients with medium (> 2.5 and less than or equal to 5.0 cm; 52%) or large (> 5.0 cm; 50%) AVMs (P = 0.0001). The 48 of 94 AVMs (51%) with deep venous drainage were more likely to have hemorrhage (P = 0.0219) than were those with superficial drainage (24 of 73 [33%]). Deep drainage was a predictor of hemorrhage even in the subgroup of medium and large supratentorial AVMs (P = 0.005). There was no difference in draining vein pressure (n = 18) between groups (21 +/- 10 and 19 +/- 11 mm Hg, respectively; P = 0.7812). FMAP (n = 52) was higher in the hemorrhage than in the nonhemorrhage group (44 +/- 13 versus 34 +/- 10 mm Hg; P = 0.0007) but was only weakly related to the size of the lesion (largest dimension) (y = -0.74x + 40; r = 0.09). Unlike FMAP, TCD velocities correlated well with largest dimension (n = 76; y = 15x + 86; r = 0.55). Although the hemorrhage group demonstrated lower mean flow velocities (94 +/- 40 versus 114 +/- 33; P = 0.0236), the absolute differences were small, suggesting that TCD indices are more related to size than propensity for hemorrhage. By the use of a multiple logistic regression model, in the subset of patients with medium or large AVMs and superficial venous drainage (the group with the lowest identified risk of intracerebral hemorrhage), FMAP had a strong influence on the incidence of intracerebral hemorrhage, (P = 0.0086), but TCD velocities did not. In summary, smaller nidus size and the presence of deep venous drainage are independent predictive factors that may increase the risk of hemorrhage from AVMs. Finally, higher FMAP is an important factor in the pathophysiology of hemorrhage from AVMs and not just a consequence of lesion size.