功能區(qū)亞型是否影響動靜脈畸形手術(shù)的預(yù)后?（Does eloquence subtype influence outcome following arteriovenous malformation surgery?）

　　英文簡介：

　　OBJECTIVE Although numerous arteriovenous malformation (AVM) grading scales consider eloquence in risk assessment,none differentiate the types of eloquence. The purpose of this study was to determine if eloquence subtype affects clinical outcome.

　　METHODS This is a retrospective review of a prospectively collected clinical database of brain AVMs treated with microsurgery in the period from 1997 to 2017. The only inclusion criterion for this study was the presence of eloquence as defined by the Spetzler-Martin grading scale. Eloquence was preoperatively categorized by radiologists. Poor outcome was defined as a modified Rankin Scale (mRS) score 3-6, and worsening clinical status was defined as an increase in the mRS score at follow-up. Logistic regression analyses were performed.

　　RESULTS Two hundred forty-one patients (49.4% female; average age 33.9 years) with eloquent brain AVMs were included in this review. Of the AVMs (average size 2.7 cm), 54.4% presented with hemorrhage, 46.2% had deep venous drainage, and 17.0% were diffuse. The most common eloquence type was sensorimotor (46.1%), followed by visual (27.0%) and language (22.0%). Treatments included microsurgery alone (32.8%), microsurgery plus embolization(51.9%), microsurgery plus radiosurgery (7.9%), and all three modalities (7.5%). Motor mapping was used in 9% of sensorimotor AVM cases, and awake speech mapping was used in 13.2% of AVMs with language eloquence. Complications occurred in 24 patients (10%). At the last follow-up (average 24 months), 71.4% of the patients were unchanged or improved and 16.6% had a poor outcome. There was no statistically significant difference in the baseline patient and AVM characteristics among the different subtypes of eloquence. In a multivariate analysis, in comparison to visual eloquence, both sensorimotor (OR 7.4, p = 0.004) and language (OR 6.5, p = 0.015) eloquence were associated with poor outcomes. Additionally, older age (OR 1.31, p = 0.016) and larger AVM size (OR 1.37, p = 0.034) were associated with poor outcomes.

　　CONCLUSIONS Unlike visual eloquence, sensorimotor and language eloquence were associated with worse clinical outcomes after the resection of eloquent AVMs. This nuance in AVM eloquence demands consideration before deciding on microsurgical intervention, especially when numerical grading systems produce a score near the borderline between operative and nonoperative management.

　　中文簡介：

　　目的：雖然許多動靜脈畸形(AVM)分級量表在風(fēng)險評估中考慮了腦功能區(qū)，但沒有一個能區(qū)分腦功能區(qū)的類型。本研究的目的是確定腦功能區(qū)亞型是否影響臨床結(jié)果。

　　方法：回顧性分析1997 - 2017年顯微外科手術(shù)治療腦動靜脈畸形的臨床資料。本研究的納入標準是由Spetzler-Martin分級量表定義的腦功能區(qū)的存在。術(shù)前放射學(xué)家對雄辯進行了分類。不良結(jié)局定義為改良Rankin評分(mRS) 3-6分，臨床狀態(tài)惡化定義為隨訪時mRS評分增加。進行Logistic回歸分析。

　　結(jié)果：241例(49.4%女性;平均年齡33.9歲)，擁有雄辯的大腦AVMs。AVMs平均大小為2.7 cm，出血占54.4%，深靜脈引流占46.2%，彌漫性占17.0%。較常見的腦功能區(qū)類型是感覺運動(46.1%)，其次是視覺(27.0%)和語言(22.0%)。治療包括單純顯微外科手術(shù)(32.8%)、顯微外科手術(shù)加栓塞(51.9%)、顯微外科手術(shù)加放射外科手術(shù)(7.9%)和全部三種方式(7.5%)。9%的感覺運動AVM病例使用運動映射，13.2%的語言腦功能區(qū)AVM病例使用清醒語音映射。并發(fā)癥24例(10%)。在較后一次隨訪中(平均24個月)，71.4%的患者病情沒有改變或好轉(zhuǎn)，16.6%的患者預(yù)后較差。不同類型腦功能區(qū)的基線患者和AVM特征無統(tǒng)計學(xué)差異。在多變量分析中，與視覺腦功能區(qū)相比，感覺運動(或7.4,p = 0.004)和語言(或6.5,p = 0.015)腦功能區(qū)都與不良結(jié)果相關(guān)。此外，年齡(或1.31,p = 0.016)和AVM大小(或1.37,p = 0.034)與不良預(yù)后相關(guān)。

　　結(jié)論：與視覺雄辯術(shù)不同，感覺運動和語言雄辯術(shù)在切除雄辯性AVMs后的臨床效果較差。AVM爭論的這種細微差別需要在決定顯微外科手術(shù)干預(yù)之前加以考慮，特別是當數(shù)值分級系統(tǒng)在手術(shù)和非手術(shù)處理之間產(chǎn)生分界時。

　　腦動靜脈畸形(AVMs)是顱內(nèi)血管病變的異質(zhì)性組，有許多不同的管理模式，包括觀察、顯微外科手術(shù)、放射外科手術(shù)、栓塞，較常見的是聯(lián)合治療。為了更好地了解顯微外科手術(shù)、放射外科手術(shù)和栓塞手術(shù)后的結(jié)果，人們開發(fā)了許多不同的分級量表。分級量表用于了解治療風(fēng)險和選擇患者進行特定治療。較常用的顯微外科分級量表是Spetzler-Martin (SM)量表，該量表根據(jù)AVMs的大小、靜脈引流和腦功能區(qū)，將AVMs分為1至5個等級。

　　雖然這些等級量表中的大多數(shù)都考慮了大腦的腦功能區(qū)，但它們都無法區(qū)分腦功能區(qū)的類型。一個例外可能是基于無線電檢測的分級系統(tǒng)，它考慮到了AVM定位，這是腦功能區(qū)類型的一個替代。因此，例如，在馬達帶中有AVM的病人，在光學(xué)輻射中可能得到與有AVM的病人相同的等級。這些結(jié)構(gòu)的損傷可能導(dǎo)致不同的神經(jīng)功能缺陷，對整體臨床結(jié)果的影響可能是可變的。人們對損傷至腦功能區(qū)距離(LED)有的興趣，但對具體腦功能區(qū)類型切除風(fēng)險的評估尚缺乏研究。本研究的目的是確定腦功能區(qū)類型如何影響臨床結(jié)果。我們假設(shè)切除有感覺運動腦功能區(qū)的動靜脈畸形會比切除有語言、視覺或協(xié)調(diào)腦功能區(qū)的動靜脈畸形的臨床效果更差。

　　圖示：以功能區(qū)類型為例的圖像:感覺運動(A)、語言(B)、視覺(C)、胼胝體(D)、丘腦(E)、小腦深部核(F)和腦干(G)。

　　該研究主要人員之一為INC國際神經(jīng)外科醫(yī)生集團旗下組織國際神經(jīng)外科顧問團(WANG)成員Michael T. Lawton 教授。Michael T. Lawton 教授是當今國際上享有盛譽的腦血管病教授，他專注各腦血管病、腦動脈瘤、動靜脈畸形、海綿狀畸形、血管搭橋、中風(fēng)、顱底腫瘤的手術(shù)治療，對于較大而復(fù)雜的腦動脈瘤手術(shù)尤為精通。此外，他還提供中樞、外周和自主神經(jīng)系統(tǒng)疾病的手術(shù)和非手術(shù)治療(即預(yù)防、診斷、評估、治療、重癥監(jiān)護和康復(fù))，包括其支持結(jié)構(gòu)和血管供應(yīng);評估和治療改變神經(jīng)系統(tǒng)功能或活動的病理過程。對于腦紊亂、顱外頸動脈、椎動脈、腦垂體紊亂、脊髓/腦膜和脊柱疾病(包括可能需要通過脊柱融合或器械治療的疾病)等有豐富經(jīng)驗。目前擁有4400余例腦動脈瘤、800余例動靜脈畸形和1000余例海綿狀畸形患者的成功治療經(jīng)驗。

• 文章標題：功能區(qū)亞型是否影響動靜脈畸形手術(shù)的預(yù)后?
• 更新時間：2019-11-14 16:30:03