| Background and purposeBecause of the complexity, diversity, high fatality rate and disability rate, brain arteriovenous malformation(BAVM) is always a difficult problem to neurosurgeons. The aim of treatment for BAVM is to completely remove or block Nidus, eliminate or reduce the risk of rupture and bleeding of BAVM, extremely protect nerve function, restore normal blood circulation of brain tissue. In recent years, with the rapid devel-opment of microneurosurgical techniques, the technology of neural involvement, nerve radiosurgery and nervous anaesthesia, the surgical treatment of BAVM has made great progress. At present, the method of surgical treatment of BAVM mainly includes neurosurgery microsurgery resection, endovascular embolization and intervention treatment, stereotactic radiosurgery treatment and the comprehensive treatment of the combination of the above three methods. Although each of them has advantages, each of them also has certain limitation at the same time. So far, there is no standardized treatment for reference. By reviewing the treatment experience of the 67 cases of BAVM, combinating related literature review, comparing therapeutic effect of the three methods of microscopic surgery, endovascular interventional embolization and conservative treatment, at the same time, analysising the possible influence factors of the therapeutic results of BAVM, this study discusses ideally and effectively individualized therapeutic regimen of BAVM, providing reference for clinical treatment.MethodsSelected from the BAVM patients discharged from the second neurosurgery in the first affiliated hospital of kunming medical university during March 2008 to Decem-ber 2014, we take 67 patients who confirmed to be BAVM through DSA/CTA/MRA and surgery and conformed with "new inclusion criteria "as research objects. After perfecting the relevant inspection before surgery, we detailed patients and their fami- lies that the treatments of BAVM included neurosurgery microsurgery resection, en-dovascular embolization and intervention treatment and conservative therapy, they had their own advantages and disadvantages, the patients and their families could cho-ose from them freely. According to their choice, we randomly divided them into three groups:microsurgical group 28 cases (n=28.42%), intravascular embolization and in-tervention group 21 cases (n=21.31%), conservative therapy group 18 cases (n= 18.27%). The surgery group did a BAVM excision under a microscope through the general anesthesia and endotracheal intubation,8 cases of the group combined with intracranial hematoma formation did emergent intracranial hematoma removal+ BAVM resection,3 cases of the group did a bone flap decompression because of brain swelling after BAVM resection. The pathology of 28 cases after the surgery confirm-ed the diagnosis. The intervention group did Onyx-18 glue (1.5mL/bottle) supersel-ective interventional embolization under General anesthesia.13 cases of the group did only one embolization, among them,6 cases one-time finished,1 case relapsed; 6 cas-es did twice embolization, including 2 cases finished at the second time, lcase did third embolization,1 case failured and automatic transferred. Conservative therapy group mainly prevented and treated epilepsy, nourished nerves and so on, and acco-rding to the patient’s own condition, selecting 6-12 month regularly reviewed head CT/MRI/DSA. All patients were followed up for 2-36 months. Main observation indexes included GOS prognostic score after treatment, effective rate of treatment, complication incidence and Patients hospitalized days, comparison between the three groups was through x2 test.Results1. The male/female ratio of 67 patients with BAVM was 1.6:1.0, the average age was (34.9±16.3), the patients from 20 to 50 years old accounted for 58.2%, the patients whose lesions located in single lobes accounted for 65.7%, the patients whose lesions across two or more lobes accounted for 20.9%, on the tentorium cerebelli accounted for 95.5%, under the tentorium cerebelli accounted for 4.5%. Major clinical manifestations were headache61.2%, hemorrhage46.3%, epilepsy23.9% and nerve dysfunction38.8%. Spetzler-Martin class Ⅰ～ⅤV respectively accounted for 7.5%, 26.9%,31.1%,26.9% and 26.9%.2. In microsurgical group, Spetzler-Martin class Ⅰ, Ⅱ level accounted for 46.4%, Ⅲ～Ⅴ level accounted for 53.6%, the total effective rate of surgery 82.1%; In intravascular embolization and intervention group, Spetzler-Martin class Ⅰ,Ⅱ level accounted for 14.3%, Ⅲ～Ⅴ level accounted for 85.7%, the total effective rate of surgery 71.4%, the incidence of complications 19.0%; in conservative therapy group, Spetzler-Martin class Ⅰ, Ⅱ level accounted for 38.9%, Ⅲ～Ⅴ level accounted for 61.1%, effective rate of treatment22.2%.3. Compared the GOS score after treatment, the incidence of complications after treatment of the patients of three groups:In microsurgical group, the recovered well proportion of GOS score was higher than that of Intravascular interventional embolization group and conservative treatment group, the proportion of moderately severe disability, plant survival and death was less than that of intravascular interventional embolization group and conservative treatment group. In Intravascular interventional embolization group, the recovered well proportion of GOS score was higher than that of conservative treatment group, the proportion of moderately severe disability, plant survival and death was less than that of conservative treatment group, the differences were statistically significant (x2=23.844,P<0.05)4. Compared the hospitalization days of three groups:the average hospitalization days of microsurgical group was (25.9±9.8) days, the average hospitalization days of Intravascular interventional embolization group was (13.5±12.4) days, the average hospitalization days of conservative treatment group was (21.4±8.6) days. The average hospitalization days of conservative treatment group was higher than that of endovascular interventional embolization group, but lower than that of microsurgical group, compared the three groups, the differences were statistically significant (x2=7.130,P<0.05)Conclusions1. The morbidity peak of BAVM is 20～50 years old, the number of men is more than that of women, more than 90% occurs on the tentorium cerebelli, the main symptoms are hemorrhage, headache, epilepsy and nerve dysfunction.2. Microsurgical resection is still the main and the most effective treatment of BAVM, way and prognosis is good, and the complication rate is relatively low. It is easy to be patients. Each patient-specific, should be considered the focus of Spetzler-Martin grade, Angioarchitecture and timing of treatment and the patient’s own factors, to develop individualized treatment plan a suitable patient.3.The average hospitalization days of the BAVM patients treated with endovascular interventional embolization is the least as well as the average hospitalization days of the BAVM patients treated with microsurgical resection is the longest. |
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