Microsurgery for cerebral arteriovenous malformations: subgroup outcomes in a consecutive series of 288 cases
Microsurgery for cerebral arteriovenous malformations: subgroup outcomes in a consecutive series of 288 cases
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DOI：
10.3171/2016.4.jns153017
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发表时间：
2017-04-01
影响因子：
4.1
通讯作者：
Bostrom, Azize
中科院分区：
文献类型：
--
作者：
Schramm, Johannes;Schaller, Karl;Bostrom, Azize
目的本研究的目的是回顾连续的单外科医生系列显微外科切除脑动静脉畸形（AVM）后的结果。对临床和影像学数据进行了分析，以解决ARUBA（未破裂脑动静脉畸形随机试验）后AVM治疗的以下问题。1)未破裂或破裂AVM的患者在长期随访时是否表现更好？2)Ponce A级（Spetzler-Martin I级和II级）患者与Ponce B级和C级患者（Spetzler-Martin III级和IV级）之间的差异是否有意义且适用于手术实践？3)该手术系列中符合ARUBA资格的患者与ARUBA中报告的结果相比如何？方法：1983年至2012年期间，由同一名外科医生（J.S.）对288例脑AVM患者进行了显微手术切除。这是一项代表连续系列的前瞻性病例收集研究。结果基于前瞻性收集的早期结果数据，并辅以回顾性收集的94%病例的随访数据。分析的数据包括初始表现、Spetzler-Martin分级、闭塞率、手术和神经系统并发症以及栓塞或放射外科预处理的频率。使用“小AVM”、Spetzler-Martin I级和II级以及符合ARUBA条件的AVM亚组对总队列进行比较。结果初始表现为50.0%的患者出血，43.1%的患者癫痫发作。该系列包括53例Spetzler-Martin I级（18.4%）、114例Spetzler-Martin II级（39.6%）、90例Spetzler-Martin III级（31.3%）、28例Spetzler-Martin IV级（9.7%）和3例Spetzler-Martin V级（1.0%）AVM。有144例未破裂病例和104例ARUBA合格病例。39例（13.5%）使用了预栓塞。全系列和小AVM亚组的闭塞率分别为99%和98.7%。平均随访时间为64个月。39.2%的患者出现早期神经功能恶化，其中12.2%为永久性功能障碍，5.6%为永久性显著功能障碍，死亡率为1.7%（n = 5）。AVM小于3 cm（7.8%的患者永久性缺损，3.2%的患者永久性显著缺损）和Ponce A级状态（7.8%的患者永久性缺损，3.2%的患者显著缺损）的患者结局更好。在所有病例中，未破裂AVM的新发缺陷率略高（但死亡率为0），并且在小AVM和Ponce A级亚组中。未破裂的Spetzler-Martin I级和II级病变的结局最好（1.8%永久性显著缺损），符合ARUBA条件的Spetzler-Martin I级和II级病变的永久性显著缺损率略高（3.2%）。将显微外科AVM切除术集中在小于3 cm的未破裂病变或Spetzler-Martin I级和II级病变上，是将长期发病率降至最低的良好策略。精心选择的显微手术病例比多模式干预（如ARUBA治疗组）或单独保守治疗的结局更好。长期的前瞻性数据收集是有价值的。
OBJECTIVE The objective of this study was to review the outcomes after microsurgical resection of cerebral arteriovenous malformations (AVMs) from a consecutive single-surgeon series. Clinical and imaging data were analyzed to address the following questions concerning AVM treatment in the post-ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) era. 1) Are the patients who present with unruptured or ruptured AVMs doing better at long-term follow-up? 2) Is the differentiation between Ponce Class A (Spetzler-Martin Grade I and II) patients versus Ponce Class B and C patients (Spetzler-Martin Grade III and IV) meaningful and applicable to surgical practice? 3) How did the ARUBA-eligible patients of this surgical series compare with the results reported in ARUBA?METHODS Two hundred eighty-eight patients with cerebral AVMs underwent microsurgical resection between 1983 and 2012 performed by the same surgeon (J.S.). This is a prospective case collection study that represents a consecutive series. The results are based on prospectively collected, early-outcome data that were supplemented by retrospectively collected, follow-up data for 94% of those cases. The analyzed data included the initial presentation, Spetzler-Martin grade, obliteration rates, surgical and neurological complications, and frequency of pretreatment with embolization or radiosurgery. The total cohort was compared using "small-AVM," Spetzler-Martin Grade I and II, and ARUBA-eligible AVM subgroups.RESULTS The initial presentation was hemorrhage in 50.0% and seizures in 43.1% of patients. The series included 53 Spetzler-Martin Grade I (18.4%), 114 Spetzler-Martin Grade II (39.6%), 90 Spetzler-Martin Grade III (31.3%), 28 Spetzler-Martin Grade IV (9.7%), and 3 Spetzler-Martin Grade V (1.0%) AVMs. There were 144 unruptured and 104 ARUBA eligible cases. Preembolization was used in 39 cases (13.5%). The occlusion rates for the total series and small AVM subgroup were 99% and 98.7%, respectively. The mean follow-up duration was 64 months. Early neurological deterioration was seen in 39.2% of patients, of which 12.2% had permanent and 5.6% had permanent significant deficits, and the mortality rate was 1.7% (n = 5). Outcome was better for patients with AVMs smaller than 3 cm (permanent deficit in 7.8% and permanent significant deficit in 3.2% of patients) and Ponce Class A status (permanent deficit in 7.8% and significant deficit in 3.2% of patients). Unruptured AVMs showed slightly higher new deficit rates (but 0 instances of mortality) among all cases, and in the small AVM and Ponce Class A subgroups. Unruptured Spetzler-Martin Grade I and II lesions had the best outcome (1.8% permanent significant deficit), and ARUBA-eligible Spetzler-Martin Grade I and II lesions had a slightly higher rate of permanent significant deficits (3.2%).CONCLUSIONS Microsurgery has a very high cure rate. Focusing microsurgical AVM resection on unruptured lesions smaller than 3 cm or on Spetzler-Martin Grade I and II lesions is a good strategy for minimizing long-term morbidity. Well-selected microsurgical cases lead to better outcomes than with multimodal interventions, as in the ARUBA treatment arm, or conservative treatment alone. Long-term prospective data collection is valuable.