PREDICTORS OF SPONTANEOUS CEREBRAL AVM HEMORRHAGE

描述：（申请人摘要）AVM占一小部分 但通常影响其他健康的人 年轻的成年人，通常是在生命的生产年。主 治疗脑动静脉畸形（AVM）的原因是 预防新发或复发性颅内出血（ICH）。 然而，通过手术、血管内栓塞和 放射外科手术具有很大的风险。此外，由于ICH预防 是治疗AVM的主要动力，复杂病变的治疗风险 应低于自发性ICH的预计累积风险。 在我们的初步工作中，我们有强有力的证据表明， 血管造影和生理因素与初始 介绍ICH。此外，在一项前瞻性的初步研究中，我们 已经表明，ICH的初始表现与复发有关， 出血，这支持了这样的观点，即与出血相关的因素， 出现ICH应是复发性ICH的预测因素。总 本研究的目的是：1）完成一项前瞻性的观察性研究， 复发性自发性AVM出血研究; 2）明确定义 相关的临床、形态学和血流动力学标准 与ICH的初始表现;和3）确定可靠的集合 预测ICH的危险因素。 我们假设存在一组不同的生理和 增加自发性ICH风险的解剖条件。 此外，我们假设，一些因素与一个 ICH的发生率较低，包括a）AVM尺寸较大，B）脑内出血的发生率较低 压力，c）缺乏脑室周围深静脉引流和静脉 狭窄和d）缺乏功能失调性扩张，即，动脉瘤 阵因为，矛盾的是，这些患者的风险较低， 疾病的自然史可能经常在最高治疗 （手术）风险，需要识别该组以获得最佳结局 管理 因此，我们建议对120例AVM患者进行为期三年的研究 期使用已建立的数据库，我们将收集数据， 临床病程、标准成像（血管造影、CT、MRI），以及 生理（血管内压力）特征。我们将开发 一个统计模型，基于明确的解剖和生理 标准，用于预测自发性ICH，可与 治疗风险。我们还将能够增加拟议的120个新的 患者与我们现有的前瞻性样本（n=150），以完成 新发或复发性自发性AVM出血的观察性研究。 在资助期结束时，我们的目标是 构建和证明合理的临床试验， 治疗风险高的患者以及我们确定为低风险的患者 自然病史风险分为保守治疗组和积极治疗组， 包括非介入性，血管内， 放射外科或外科治疗。该项目将导致更好的 了解脑AVM的病理生理学和自然史 以及更有效地利用医疗资源， 合理选择患者进行复杂和多模式治疗。

DESCRIPTION: (Applicant's Abstract) AVMs represent a small proportion of the total incidence of stroke but typically affect otherwise healthy young adults, usually in the productive years of life. The primary reason to treat cerebral arteriovenous malformations (AVMs) is the prophylaxis against new or recurrent intracranial hemorrhage (ICH). However, treatment of AVMs by surgery, endovascualar embolization and radiosurgery carries a significant risk. Further, since ICH prevention is the main impetus to treat AVMs, treatment risk for complex lesions should be less than the projected cumulative risk for spontaneous ICH. In our preliminary work we have strong evidence that certain angiographic and physiologic factors are related to an initial presentation of ICH. Further, in a prospective preliminary study, we have shown that initial presentation of with ICH is related to recurrent hemorrhage, which supports the notion that factors associated with the presenting ICH should be predictive of recurrent ICH. The general objectives of this study are 1) to complete a prospective observational study of recurrent spontaneous AVM hemorrhage; 2) to explicitly define the clinical, morphologic, and hemodynamic criteria that are associated with the initial presentation of ICH; and 3) to identify a reliable set of risk factors to predict ICH. We hypothesize that there exists a set of distinct physiologic and anatomic conditions that increase the risk for spontaneous ICH. Further, we hypothesize that a number of factors are associated with a low incidence of ICH, including a) large AVM size, b) low intranidal pressure, c) lack of periventricular deep venous drainage and venous stenosis and d) lack of dysfunctional dilation, i.e., aneurysm formation. Because, paradoxically, such patients at low risk from the natural history of the disease may often by at the highest treatment (surgical) risk, this group needs to be identified for optimal outcome management. Therefore, we propose studies on 120 AVM patients over a three-year period. Using an established databank, we will collect data from clinical course, standard imaging (angiography, CT, MRI), and physiologic (intravascular pressure) characteristics. We will develop a statistical model, based on explicit anatomic and physiologic criteria, for prediction of spontaneous ICH that can be weighed against treatment risk. We will also be able to add the proposed 120 new patients to our existing prospective sample (n=150) to complete the observational study of new or recurrent spontaneous AVM hemorrhage. At the conclusion of the grant period, our goal is to be in a position to construct and justify rational clinical trials that will randomize patients with high treatment risk and what we will determine to be low natural history risk into conservative versus aggressive therapy groups, including some combination of non-interventional, endovascular, radiosurgical or surgical treatment. The project will lead to a better understanding of the pathophysiology and natural history of cerebral AVMs and a more cost-effective use of medical resources by allowing more rational selection of patients for complex and multi-modal treatment.