颅颈交界区(CCJ)动静脉瘘(AVF)使用神经外科或血管内选择进行治疗;然而,对于最安全和最有效的治疗方法仍未达成共识。本研究比较了神经外科手术和腔内手术治疗CCJAVF的结果,特别是关于再治疗,并发症,和结果。
这是一项由日本神经脊髓学会授权的多中心队列研究。分析了2009年至2019年在29个中心接受神经外科或血管内治疗的CCJAVF连续患者的数据。主要终点是手术的再治疗率。次要终点是总并发症发生率,缺血并发症发生率,死亡率,治疗后神经状态的变化,再治疗的独立危险因素,和糟糕的结果。
97例患者接受了神经外科手术(78例)或血管内治疗(19例)。神经外科组的复治率为2.6%(2/78例),血管内组为63%(12/19例)(p<0.001)。神经外科和血管内组的总并发症发生率分别为22%和42%,分别(p=0.084)。神经外科和血管内组的缺血性并发症发生率分别为7.7%和26%,分别(p=0.037)。缺血性并发症包括8例脊髓梗塞,2个脑干梗塞,和1个小脑梗塞,导致永久性的神经功能缺损.神经外科和血管内组的死亡率分别为2.6%和0%,分别为(p>0.99)。2例患者死于全身并发症。改良Rankin量表(mRS)评分改善的患者比例在神经外科和血管内组分别为60%和37%,分别,中位随访时间为23个月(p=0.043)。多因素分析确定血管内治疗是与再治疗相关的独立危险因素(OR54,95%CI9.9-300;p<0.001)。与不良预后(术后mRS评分为3或更高)相关的独立危险因素是治疗前mRS评分为3或更高(OR13,95%CI2.7-62;p=0.001)和并发症(OR5.8;95%CI1.3-26;p=0.020)。
对于CCJAVF患者,神经外科治疗比血管内治疗更有效,更安全,因为再治疗和缺血性并发症发生率较低,预后更好。
OBJECTIVE: Craniocervical junction (CCJ) arteriovenous fistulas (AVFs) are treated using neurosurgical or endovascular options; however, there is still no consensus on the safest and most effective treatment. The present
study compared the treatment results of neurosurgical and endovascular procedures for CCJ AVFs, specifically regarding retreatment, complications, and outcomes.
METHODS: This was a multicenter cohort
study authorized by the Neurospinal Society of Japan. Data on consecutive patients with CCJ AVFs who underwent neurosurgical or endovascular treatment between 2009 and 2019 at 29 centers were analyzed. The primary endpoint was the retreatment rate by procedure. Secondary endpoints were the overall complication rate, the ischemic complication rate, the mortality rate, posttreatment changes in the neurological status, independent risk factors for retreatment, and poor outcomes.
RESULTS: Ninety-seven patients underwent neurosurgical (78 patients) or endovascular (19 patients) treatment. Retreatment rates were 2.6% (2/78 patients) in the neurosurgery group and 63% (12/19 patients) in the endovascular group (p < 0.001). Overall complication rates were 22% and 42% in the neurosurgery and endovascular groups, respectively (p = 0.084). Ischemic complication rates were 7.7% and 26% in the neurosurgery and endovascular groups, respectively (p = 0.037). Ischemic complications included 8 spinal infarctions, 2 brainstem infarctions, and 1 cerebellar infarction, which resulted in permanent neurological deficits. Mortality rates were 2.6% and 0% in the neurosurgery and endovascular groups, respectively (p > 0.99). Two patients died of systemic complications. The percentages of patients with improved modified Rankin Scale (mRS) scores were 60% and 37% in the neurosurgery and endovascular groups, respectively, with a median follow-up of 23 months (p = 0.043). Multivariate analysis identified endovascular treatment as an independent risk factor associated with retreatment (OR 54, 95% CI 9.9-300; p < 0.001). Independent risk factors associated with poor outcomes (a postoperative mRS score of 3 or greater) were a pretreatment mRS score of 3 or greater (OR 13, 95% CI 2.7-62; p = 0.001) and complications (OR 5.8; 95% CI 1.3-26; p = 0.020).
CONCLUSIONS: Neurosurgical treatment was more effective and safer than endovascular treatment for patients with CCJ AVFs because of lower retreatment and ischemic complication rates and better outcomes.