出血発症の重症脳/硬膜動静脈奇形に対する超急性期治療

抄録

As most of cerebral arteriovenous malformations (AVMs) and dural AVMs (dAVM) are electively treated, their urgent treatment has been rarely reported. We therefore sought to evaluate the clinical characteristics and treatment strategy for comatose patients with AVM/dAVM transported by ambulance. Within the past 10 years, 36 patients with AVM/dAVM (30 AVM and 6 dAVM, 21 men and 15 women with an average age of 48.6 years) have arrived at our institution. Among these, 23 patients had a Glasgow Coma Scale (GCS) grade of 6 or less and 16 patients presented with pupillary abnormality.
The average amount of intracerebral hematoma was 44.2 ml. The AVM was removed after cerebral angiography in 19 patients, whereas 8 underwent hematoma evacuation and 3 underwent ventricular drainage prior to angiography. An AVM was simultaneously extirpated in 6 patients at the initial craniotomy without angiography, 4 of which were preoperatively diagnosed as hypertensive cerebral hemorrhage. The Spetzler-Martin Grade was I in 9, II in 16, III in 4 and V in 1 patient, respectively. The AVM/dAVM was extirpated in 32 patients. The average time from arrival to emergency surgery was 213 minutes. Massive cerebral hematoma tended to be caused by small AVM. Their modified Rankin Scale assessed at discharge was 0 in 3, 1 in 6, 2 in 2, 3 in 1, 4 in 4, 5 in 12, 6 in 6 patients, respectively. Poor outcome was related to older age, poor GCS and Apache II score, and large amount of hematoma volume.
Prompt resuscitation and surgical decompression along with neurointensive care appeared to be mandatory to save these AVM/dAVM patients showing impending herniation.