| Background:The cerebral arteriovenous malformations (cAVMs) are congenital malformations that occur in the embryonic stage of three or four weeks, due to the disturbance of the vascular system development,and formed direct communications between arteries and veins. Which are found in average31.2years older and males are a few more than females. In1984, McCormick has reported5754autopsy that216cases (3.18percent) had intracranial vascular malformation (IVM), including30bodies were comfirmed cAVMs of0.152percent of morbidity rate; The retrospective study performed by Jessurun showed that symptom of cAVMs examined was111of one hundred thousand man-year in Antilles Archipelago of Holand between1980and1990. however, morbidity rate of hereditary hemorrhagic telangiectasis(HHT) was higer which made symptomatic cAVMs detectives obviously; Brown collected the records of one hundred thousand persons in Olmsted of Minnesota State of American base on retrospective study about FVM rang1965form1992and reported the results step-by-step continuesly that the detective of IVM and cAVMs trends to high gradually; the reasons that the advantage technical of brain imaging developed the detective of cAVMS. Up to1992,the last results showed the total of IVM was48(accounted for2105of one hundred thousand man-year),including there were26cAVMs patients (accounted for 1111of one hundred thousand man-year), the prospective study done by Al-Shahi R[3] reveal that the cerebral vascular malformation was detected0.0227%o,and The cerebral arteriovenous malformations (cAVM)0.0112‰more than16years older in Scotland areas between1999and2000.the respective research on2086cAVMs patients shows that was found between20and40years older by internal ZHAO-JZ[4].in addition, some researchers found according to800patients in the Research center of neurosurgery of Beijing that supertentorial location of cAVMs was90.8%,and infratentorial location was9.2%.There were no difference between two hemisheres of the accidence of cAVMs, which account for2%in both, near to midline of cerebra8%,generally most of cAVMs were found one of sides. There is no symptoms in the minor cAVMs generally,however,larger lesions may have no symptoms.The clinical manifestation of cAVMs always show haemorrhage or epilepsy, and so on. Firstly, haemorrhage:Haemorrhage is the most common phenomenon, half of patients of cAVMs are suffered cerebral haemorrhage which generally happen to cerebral tissue,cerebral ventricle or subarachnoid space and so on, there are some relationship between the location or size of cAVMs and bleeding,Abnormal extend vein may be cause haemorrhage of cAVMs that is not different from aneurysm which causes a great deal of volume blood. There were one or more aneurysms accompany with cAVMs, including account for22.8percent,in101patients with cAVMs through revealed by Willinsky which may located proximal end or distant end of inner cAVMs, some far form the lesion; The patients of cAVMs with aneurysms performed elder age, epilepsy, hemorrhage and dysfunction of neurology,because of high flow capacity of cAVMs, more than pure cAVMs. Some patients manifested headache, epilepsy or focus disturbance and so on before haemorrhage, secondly,Epilepsy:the type of epilepsy varies different that was made through cerebral haemorrhage or others. The reason was that direct communications between arteries and veins according to lesion,leading to seizure, antiepileptic drug is not work,that cerebra ischemia or cerebral tissue degeneration when the lesions discharge electricity among the areas of frontal temporal lobe,and so on. The abnormal vessel was detected through MRI,MRA or DSA.thirdly, Headache:cerebral haemorrhage generally cause headache which shows headache consistently and repeatitly. Usually, the headache, recurrently,showed distending pain on one or more areas which was used drug to relief pain. Fourthly, Focus Neurological disorder:The disorder of neurology was founded according to location of cAVMs, compressing of cerebral haemorrhage,the cerebral blood circulation and the areas of encephalanalosis. For example,the lesion in frontal,if located dominant hemisphere, usually manifest epileptic seizures, heahache, intelligence and emotion disorder which occur language handicap,limb paralytic and weak facial myodynamia; the lesion in temporal always perform,if located dominant hemisphere, epileptic seizures, heteroptics, olfactory hallucination which occur nominal aphasia and acoustic aphasia; In parieto&occipital lobe which show focus epileptic seizures, cortical sensory disturbance, alexia, apraxia, computation disturbance, hemiablepsia and spatial disorientation; In basal ganglia show fremitus, heavy cumbersome limbs, Huntington’s disease,limb disturbance of the condition of bleeding, and so on; In pons and medulla oblongata always show neck pain, nausea, emesis, fibrae pyramidales symptom, ataxy, cranial nerve paralytic, Respiratory arrest and asystole in serious bleeding. Fifthly Others:there are any atypical symptoms. Mental symptom was made in the frontal, temporal, transverse sinus, sigmoid sinus of cAVMs which manifested intracranial murmur, increased intracranial pressure, tinnitus. The heart failure was only presentation that formed direct communications between arteries and veins, especially, Bichat’s canal. In addition,there existed gastro-intestinal tract spasm, and other complications. The elderly patients with cAVMs always were neglected,the reason was that low morbidity, high mortality for rapid change of occurrence,cerebral hamorrhage for hypertension,or other vessel accidents,hidden the true causes. Kimberly thought the high rate of hemorrhage accompany with change of age in relation to the body changes as age development; because of a little cases about cAVM of elderly patients,there were no a lot of cases reports,which show the morbidity of cAVMs, or not concerned. The diagnoses of cAVMs depended on CTA,MRA,or DSA. The way of therapy of lesion are microsurgery,vascular interventional therapy, radiotherapy, conservative treatment, Comprehensive treatment, and so on. so cAVMs are extremely harmful for middle age and youth health, however, the incidence of cAVMs was in youth more than elderly patients that account for less than10%,in addititon, there are minor relative researchs about elderly patients in home and abroad result of not enough to understand the clinic characteristic and therapy, as elderly society developed,so that the detective of cAVMs trends to higher and affect the quality of lives in elderly patients, It is necessary that we further study the clinic feature and the kind of treatment methods.Methods:"cerebral arteriovenous malformations","vascular malformations","AVM" were inputted database of Zhujiang hospital In order to search relative patients, check cases,images or follow-up situation which about clinical manifestation, angioarchitecture, location and therapy between January2000to December2011, And analysis of clinical manifestation, angioarchitecture, location and therapy through retrospect to511AVMs, including28elderly patients (≥60), in the department of neurosurgery of zhujiang hospital of South Medical University.However, the patients of cAVMs, except for Dural arteriovenous fistulas (DAVF),Cavernous angiomas,carotid-cavernous fistula(CCF),another location of body of vascular malformations and so on,who were confirmed by digital subtraction angiography (DSA),CTA,MRA or Histopathology. Including, AXIOM artis DTA machine was used to examine cerebral vessel through puncturing femoral to put6F sheath, heparinizing general blood, linking catheter system to flushing with Normal Saline (NS) continuously in general anesthesia, first of all, aortic arch angiography was performed through5F catheter called "pig tail", and then cerebral vessel angiography done with5F vertebrarterial canal, three-dimensional image (3-D) done to check the situation of brain vessel. Selected patients needed to examination and evaluation which content complete blood count, routine urine test, liver function, renal function, comprehensive metabolic panel, coagulation function test, sternum, electrocardio gram, abdominal doppler ultrasound, pulmonary function test, or image examination, and then, doctor connect those results with the requirement of patient and relatives to determine the end therapeutic strategy. Strategy of treatment contents microsurgery, vessel interventional therapy, radiosurgery, conservational treatment, including, after microsurgery and vessel interventional therapy, the patients should be give sedation, lie in bed, bowels open, strictly control blood pressure over three days in order to avoid normal perfusion pressure breakthrough syndrome (NPPB), DSA was performed in emergency in order to identify feeding arteries and draining vein when cAVMs broke led to hemorrhage of supratentorial blood volume over30milliliter, subtentorial over10milliliter according to CT in department of emergency. If necessary we can perform interventional therapy partly, secondly, clean hematoma and excise the lesion through microsurgery. if not fit operation, we chose to clear hematoma firstly, up to next operate lesion or interventional therapy. After relative treatments, we follow-up patients on out patient clinic, telephone interview, hospitalization by1-9months. the interview content that symptom before treatment, change situation of therapy,recovery of complication, recurrence of hemorrhage and therapy, renew manifestation and so on. Results:the morbidity of elderly patients of cAVMs is5.4%, clinical presentations that hemorrhage are20, seizure4, headache2, facial tic1and tinnitus1. supratentorial or infratentorial location22or6. The maximum diameter of AVM less than3centimeter are11,rang3centimeter from6centimeter16, more than6centimeter1including the most largest cAVM is8cm*5cm*5cm,the smallest0.5cm*0.8cm*0.2cm; Functional areas are21,non-functional7; Deep vein drainage are15, two-way is1, superficial11; Grade I is1, grade II are7, Ⅲ13, Ⅵ6,grade V is1; there is significant changes of symptom between pre-and pro-operation in27patients through treatment which contents endovascular embolization18, operation6,observation2,radiotherapy2. However, only one patient became worse in treatments.Conclusion:the elderly patient of cAVMs with low morbidity that most symptoms was hemorrhage,and lesion mostly located supratentorial region. Active intervention therapy, including operating, endovascular embolization, radiotherapy, observation, is helpful of prognosis and quality of lives... |
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