The Clinical Features And Treatment Of Particular Location Or Types Of Brain Arteriovenous Malformations In Patients

Section ?(Charpter ?)Posterior fossa brain arteriovenous malformations:Clinical features and outcomes of endovascular embolization,adjuvant microsurgery and radiosurgeryBackground:Posterior fossa brain arteriovenous malformations(PFbAVM)are relatively rare brain disorders but have a high risk of hemorrhage.Endovascular embolization to reduce the lesion size before treatment may improve the outcome of PFbAVM.Methods:A total of 63 patients with PFbAVMs were treated(14.1%of all AVM cases).A retrospective examination of patient baseline characteristics and outcomes was carried out.The re-hemorrhage rate,obliteration rate and modified Rankin scale(mRS)were used as measures of outcome.Results:Of the 63 PFbAVM patients 54(85.7%)exhibited hemorrhage.The cerebellar location(P = 0.007)and deep venous drainage(P =0.012)were independent predictors of hemorrhage in multivariate analyses.The mean estimated devascularization was 46.9%in the 20 patients(31.7%)treated by endovascular embolization.Complete obliteration was attained in 12 patients(67%)while 2(5.7%)were left with persisting neurological deficits and 1 had a re-hemorrhage 3 years later(annual rate of 4.6%).Favorable outcome(mRS ? 2)was obtained in the 20 patients receiving initial endovascular embolization(P = 0.039 versus preoperative mRS).Conclusion:Cerebellar location and deep venous drainage are predictors of hemorrhage in PFbAVM.Adjuvant endovascular embolization is useful and safe for PFbAVM prior to microsurgery or radiosurgery.Section ?(Charpter?)Responsible characteristics of brain arteriovenous malformations contribute to the formation of associated aneurysmsBackground:The formation of associated aneurysms(AA)related to the characteristics of bAVMs is poorly recognized.Methods:This study was performed to analyze the baseline characteristics of patients with bAVMs and AAs.The recurrent AA and residual size of bAVMs were used to evaluate the outcomes of patients after treatment.At the same time,the ROC curve was measured to gauge the relationship between the residual size of bAVMs and recurrent AAs in eligible patients.Results:Fifty(15.0%)patients with bAVMs and AA were confirmed;these patients had twice the hazard of hemorrhage as patients with only isolated bAVMs.An infratentorial location(P<0.001)and fistula(P = 0.002)were independent predictors of the formation of AAs.After a mean 22.7 months follow-up,2 patients developed recurrent AAs,and the annual recurrence rate for patients with responsible characteristics was 17.6%,but for all patients was 7.2%.The ROC curve showed that patients,specifically patients with responsible characteristics,the residual size of the cAVM was closely related to recurrent AA(P = 0.023).Conclusion:Patients with bAVMs and AA who harbor a fistula or an infratentorial location tend to form AAs.To prevent recurrent AAs and decrease the subsequent risk of hemorrhage,complete obliteration of bAVMs or retrograding over 80%size of cAVMs is recommended.Section ?(Charpter IV)Multidisciplinary care of unruptured brain arteriovenous malformations to improve symptomatic associated headacheBackground:Symptomatic headaches(SH)attributed to bAVMs are very common,but multidisciplinary care of unruptured bAVMs to improve SH remains unclear.Methods:The features of SH and headache outcomes were analyzed in a large cohort of cases after multidisciplinary care of unruptured bAVMs.An 11-point pain scale score was used to assess SH before,during,and after treatment.The death or stroke,and adverse functional outcomes(modified Rankin Scale score ? 2,mRS ? 2)were assessed following multidisciplinary care of unruptured bAVMs.Results:Twenty-three(56.1%)of 41 patients had migraine-like headaches located in occipital lobe(P<0.001),while forty(63.5%)of 63 patients had tension-type-like headaches located in frontotemporal lobe(P<0.001).For patients with tension-type-like or all types of headache,headache improvement differed between the multidisciplinary group and medical group(87.8%vs.31.8%,P<0.001;85.7%vs.40.7%,P<0.001).The risk of death or stroke did not differ between multidisciplinary group and medical group(P = 0.393),whereas the risk of adverse functional outcome(mRS ? 2)differed significantly by long-time follow-up(23.0%vs.10.0%,P ?0.022).Conclusion:Occipital unruptured bAVM is more likely to present with migraine-like headache,while frontotemporal unruptured bAVM tends to present with tension-type-like headache.The effectiveness of multidisciplinary care for unruptured bAVM to improve headache has been shown,but the natural history of unruptured bAVM patients with headache remains unclear.