背景:这篇综述的目的是总结血管造影和栓塞在脑动静脉畸形的综合多学科管理中的作用的可用数据(AVM方法:我们进行了结构化文献综述,以研究检查适应症,功效,以及在脑AVM管理背景下接受血管内治疗的患者的结局。我们对证据的质量进行了评级。建议是通过作者的共识会议达成的,然后由神经介入外科学会(SNIS)标准和指南委员会和SNIS董事会提供额外的投入。
结果:脑AVM的多学科评估和治疗不断发展。建议包括:(1)数字减影导管脑血管造影(DSA)-包括2D,3D,并在适当时重新格式化横截面视图-建议在治疗前评估大脑AVM。(I,B-NR)。(2)建议在完整的多学科治疗计划的背景下进行脑动静脉畸形的血管内栓塞,以消除AVM并治愈。(I,B-NR)。(3)手术切除前脑AVM栓塞可以有用削减术中出血量,发病率,和手术复杂性。(IIa,B-NR)。(4)脑动静脉畸形的原发性治愈性栓塞的作用尚不确定,特别是与有或没有辅助栓塞的显微外科和放射外科相比。需要进一步的研究,特别是关于AVM复发的风险。(III模棱两可,C-LD)。(5)针对脑动静脉畸形破裂的高危特征进行靶向栓塞治疗可降低再出血的风险。(IIb,C-LD)。(6)姑息性栓塞可能对治疗有症状的AVM有用,否则无法进行治愈性治疗。(IIb,B-NR)。(7)AVM栓塞作为放射外科辅助手段的作用尚未明确。需要进一步的研究。(III模棱两可,C-LD)。(8)建议在脑AVM明显治愈后进行影像学随访以评估复发。尽管非侵入性成像可用于纵向随访,在有影像学和/或临床表现的患者中,DSA仍然是残留或复发性AVM检测的金标准。(I,C-LD)。(9)改进了所有年龄的脑动静脉畸形患者的国家和国际报告,他们的治疗,治疗的副作用,他们的长期结果将增强进行临床试验的能力,并提高对这种罕见疾病的研究的严谨性。(I,C-EO)。
结论:尽管证据质量低于接受多项随机对照试验的更常见条件,血管内治疗在脑动静脉畸形的管理中具有重要作用,需要进行前瞻性研究以加强支持这些建议的数据.
BACKGROUND: The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a
consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and
Guidelines Committee and the SNIS Board of Directors.
RESULTS: The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) .
CONCLUSIONS: Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.