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1、Your company sloganYour company sloganSCISCI论文汉化汇报论文汉化汇报胡胡 芳芳 Your company sloganYour company slogan 1 1、Scientific research group Team leader:Zhang Yuerong Team members:Hu Fang,Yin Xing 2、August 2009;23(4):376386Treatment guidelines for cerebral arteriovenous malformation microsurgery脑动静脉畸形治疗指南脑动静脉
2、畸形治疗指南 RICARDO J.KOMOTAR,RICARDO J.KOMOTAR,E.SANDERCONNOLLY E.SANDERCONNOLLY Department of Neurosurgery,Columbia UniversityDepartment of Neurosurgery,Columbia UniversityYour company sloganYour company sloganLOREMLOREMLOREMLOREMLOREMBritish journal of neurosurgery(英国神经外科杂志)Source publication(来来源源杂杂志志
3、)Your company sloganYour company slogan杂杂志志简简介：介：Your company sloganYour company slogan期刊十年影期刊十年影响响因子因子变变化化Your company sloganYour company sloganAbstractAbstract The goal of cerebral arteriovenous malformation(AVM)treatment is The goal of cerebral arteriovenous malformation(AVM)treatment is to to el
4、iminate intracerebral hemorrhage risk and topreerve or maximize eliminate intracerebral hemorrhage risk and topreerve or maximize neurological functions of the patientneurological functions of the patient.Interventional planning must determine the modality orcombination of Interventional planning mu
5、st determine the modality orcombination of modalities with the greatest success rate according to patient modalities with the greatest success rate according to patient characteristics,AVM architecture,and thecapabilities of the treatment characteristics,AVM architecture,and thecapabilities of the t
6、reatment option to fulll the goals of treatment.option to fulll the goals of treatment.Although there is a lack of data from randomized trials toguide AVM Although there is a lack of data from randomized trials toguide AVM management,microsurgery is a mainstay of therapy in patients management,micro
7、surgery is a mainstay of therapy in patients receiving denitive intervention.receiving denitive intervention.In this paper,wereview current guidelines for surgical planning,risk-In this paper,wereview current guidelines for surgical planning,risk-benet analysis,and prediction of outcome in AVM patie
8、nts.benet analysis,and prediction of outcome in AVM patients.Your company sloganYour company slogan摘要摘要Absract脑AVM的治疗目标是去除脑出血风险和最大程度地保护患者神经功能治疗方案根据患者个体特点、畸形团结构和所选择治疗方式的适应范围来决定 虽然尚无随机研 究指导AVM的治疗，显微手术目前是脑AVM治疗的主要方式本文综述了现有的脑AVM外科治疗指南、风险-优势分析和预后分析Your company sloganYour company slogan介绍介绍完全消除完全消除AVMAVM病
9、灶是治疗的最终目标病灶是治疗的最终目标目前治疗方式目前治疗方式对于非功能区的小对于非功能区的小AVMAVM，显微手术切除效果已经被，显微手术切除效果已经被证明非常好，但并不适用所有证明非常好，但并不适用所有AVMAVM患者患者治疗方式选择和治疗方式选择和AVMAVM的自然病史需要综合评估后采的自然病史需要综合评估后采用多学科的治疗方法。风险评估主要取决于患者用多学科的治疗方法。风险评估主要取决于患者特点、特点、AVMAVM形态和可利用治疗方式的限制形态和可利用治疗方式的限制Your company sloganYour company slogan治疗方式治疗方式治疗方式治疗方式 立体定立体定
10、向放射向放射 血管内血管内治疗治疗显微手术显微手术Your company sloganYour company slogan患者相关因素治疗计划应该从分析患者特点开始：年龄、生存期望值、症状、既往史、家庭背景AVM相关的疾病、功能状态在手术风险中必须考虑患者症状是非常重要的考虑因素，最优先考虑的因素应为评估出血及再次出血风险，其次为癫痫或头痛 AVM有2-4%的年出血风险和终生17-90%再出血风险。出血后的1年再次出血率达6-18%。出血相关因素见表2Your company sloganYour company slogan患者相关因素基因分析研究显示基因分析研究显示TNF-a-238
11、AG TNF-a-238 AG 基因型和基因型和ApoEe2 ApoEe2 携带是出血的独立危险携带是出血的独立危险因素因素Table 2Table 2Your company sloganYour company slogan切除AVM还可能减轻相关损伤造成的功能症状，包括癫痫癫痫的控制可能受到患者癫痫起始发作年龄、病程、相关损伤位置的影响AVM相关癫痫在显微手术切除AVM后会得到更好的控制术后长期癫痫控制还需进一步研究患者相关因素Your company sloganYour company slogan在无症状AVM患者，上述的推荐治疗方式、长期出血风险、出血后的预后仍有争议诸多偏倚会影
12、响AVM自然史的研究，如选择偏倚、治疗干涉偏倚、缺乏长期随访等近期研究表明，无出血史的AVM患者治疗和不治疗的三年随访结果，并无差异长期监测可能是无出血史的AVM患者更合适的处理方式无症状无症状AVMAVMYour company sloganYour company slogan本研究显示无症状AVM脑出血死亡率达10-30%并发症发生率30-50%患者应该选择长期监测无症状无症状AVMAVMYour company sloganYour company sloganAVM结构是制定有效治疗方案的关键参考因素MRI、DSA可术前明确AVM的详细结构、解剖特点及相关动脉瘤AVM体积小、位置深、
13、形态弥撒、位置在脑室周围或脑室内、基底节区、后颅凹、高流量供血动脉、椎基底动脉供血、静脉扩张、静脉狭窄、深静脉引流、伴随动脉瘤都可致出血风险增高 AVMAVM结构结构Your company sloganYour company sloganPathogenyPathogeny Cerebral arterio venous malformation is a congenital disorder,Cerebral arterio venous malformation is a congenital disorder,embryonic development process of cer
14、ebral vascular variation embryonic development process of cerebral vascular variation and the formation of,is generally and the formation of,is generally believed that occur in the believed that occur in the embryos 45-60dembryos 45-60d.In the fourth week of embryonic,primitive.In the fourth week of
15、 embryonic,primitive brain vascular network began to form,primitive in the original brain vascular network began to form,primitive in the original blood circulation,after the original blood tube and blood circulation,after the original blood tube and differentiation of arteries,veins and capillaries
16、.In early embryos differentiation of arteries,veins and capillaries.In early embryos and primordial vein and artery is communicating,after due to and primordial vein and artery is communicating,after due to the local capillary dysplasia,lack of capillary structure,resulting the local capillary dyspl
17、asia,lack of capillary structure,resulting in a series of cerebral hemodynamic changes and the in a series of cerebral hemodynamic changes and the corresponding clinical symptoms and signscorresponding clinical symptoms and signsYour company sloganYour company sloganHarmThe short circuit is short ci
18、rcuit,which makes the The short circuit is short circuit,which makes the surrounding brain tissue is less than the effective surrounding brain tissue is less than the effective blood supply,combined with the oppression of the blood supply,combined with the oppression of the abnormal blood vessels,so
19、 that the local brain tissue abnormal blood vessels,so that the local brain tissue damage.However,the biggest threat is the rupture of damage.However,the biggest threat is the rupture of the abnormal blood vessels,resulting in subarachnoid the abnormal blood vessels,resulting in subarachnoid hemorrh
20、age or cerebral hemorrhage.hemorrhage or cerebral hemorrhage.Your company sloganYour company sloganTableTable 3 3Your company sloganYour company sloganClinical symptomsThe main clinical symptoms of patients with The main clinical symptoms of patients with intracranial intracranial arteriovenousarter
21、iovenous malformations are malformations are transient cerebral ischemia,epilepsy,transient cerebral ischemia,epilepsy,intracranial hemorrhage and so on.intracranial hemorrhage and so on.颅内动静脉畸形患者的主要临床症状有患者会反复出现短暂颅内动静脉畸形患者的主要临床症状有患者会反复出现短暂颅内动静脉畸形患者的主要临床症状有患者会反复出现短暂颅内动静脉畸形患者的主要临床症状有患者会反复出现短暂脑缺血发作、癫痫、
22、颅内出血等表现。脑缺血发作、癫痫、颅内出血等表现。脑缺血发作、癫痫、颅内出血等表现。脑缺血发作、癫痫、颅内出血等表现。Your company sloganYour company sloganAVM 显微手术一般来说是选择手术出现脑出血或者威胁生命的血肿导致脑积水，预后不佳在紧急情况下清除血肿，可迅速解除表浅AVM，不能有效切除病灶否则，应该先解决出血或血肿相关的并发症，待术后病情稳定后计划行全脑DSA，从而进一步手术手术时机手术时机Your company sloganYour company slogan手术风险手术风险I I、IIII级级AVMIII级级IV级级 预后良好预后良好92-
23、100%68-96%71-75%V级级50-70%Your company sloganYour company slogan报道发现放射治疗时程中年出血风险为3.7%，且84%的患者在放射治疗后的血管造影证实AVM完全消除放射治疗为医疗上不适合手术或者不愿意手术的I、II级患者提供了一种创伤更小的治疗方式对于小且位置深的AVM，伴随一根或两根供血动脉，尤其在基底节或丘脑，血管内栓塞是合适的治疗，因为其可以迅速提供保护，防止新的出血或再次出血 手术风险手术风险Your company sloganYour company sloganAVM患者的麻醉和其他神经外科手术在监测、血管路径、麻醉药物
24、、血管活性药物及肌松药物等方面的麻醉类似 AVM的显微手术总是涉及迅速、大量出血的风险，分离AVM的出血风险并不高，但由于术中血流动力学的改变，合并7-41%的动脉瘤出血可能性较大AVM显微手术麻醉药物选择应达到脑松弛的目的，并能较好地控制血压和处理紧急情况，建议正常血压、正常血糖水平、轻度低碳酸血症 麻醉麻醉Your company sloganYour company sloganAVMAVM血管内治疗的指征主要有血管内治疗的指征主要有显微手术前作为辅助栓塞治疗对有症状的但难以治愈的AVM进行姑息性的栓塞，以抑制或缓和症状加重对部分经选择后的患者进行根治 血管内治疗血管内治疗Your co
25、mpany sloganYour company slogan血管内治疗伴随出血（2-5%）、新的神经功能缺损（10-14%）、永久神经功能缺陷（2-5%）等并发症，及死亡（1%）栓塞作为主要治疗方式治疗AVM的消除率比较低。其效果可能在经过认真筛选的患者中尚可。对于小且位置深，有一或两根供血动脉的AVMs，尤其基底节或丘脑的AVM，血管内栓塞可以对新的出血或者再出血提供较为合适且迅速的保护 血管内治疗血管内治疗Your company sloganYour company sloganPrevention预防预防对发现的的高血压病人进行早期的严格和持久的控制措施，指导这类对发现的的高血压病人
26、进行早期的严格和持久的控制措施，指导这类对发现的的高血压病人进行早期的严格和持久的控制措施，指导这类对发现的的高血压病人进行早期的严格和持久的控制措施，指导这类病人规范口服降压药物，定期测血压，调整服药剂量，避免间断用药病人规范口服降压药物，定期测血压，调整服药剂量，避免间断用药病人规范口服降压药物，定期测血压，调整服药剂量，避免间断用药病人规范口服降压药物，定期测血压，调整服药剂量，避免间断用药很多高血压患者在平时是无症状的，也就是说这部分人群长期没有发很多高血压患者在平时是无症状的，也就是说这部分人群长期没有发很多高血压患者在平时是无症状的，也就是说这部分人群长期没有发很多高血压患者在平时
27、是无症状的，也就是说这部分人群长期没有发现自己患了高血压病，得不到及时有效的治疗。现自己患了高血压病，得不到及时有效的治疗。现自己患了高血压病，得不到及时有效的治疗。现自己患了高血压病，得不到及时有效的治疗。临床上遇到很多脑出血病人，多数是由于没有正规的降压治疗或降压临床上遇到很多脑出血病人，多数是由于没有正规的降压治疗或降压临床上遇到很多脑出血病人，多数是由于没有正规的降压治疗或降压临床上遇到很多脑出血病人，多数是由于没有正规的降压治疗或降压效果不好，间断用药而导致脑出血的发生。效果不好，间断用药而导致脑出血的发生。效果不好，间断用药而导致脑出血的发生。效果不好，间断用药而导致脑出血的发生。
28、本研究通过普通人群中进行流行病学调查，即社区医疗对常驻居民进本研究通过普通人群中进行流行病学调查，即社区医疗对常驻居民进本研究通过普通人群中进行流行病学调查，即社区医疗对常驻居民进本研究通过普通人群中进行流行病学调查，即社区医疗对常驻居民进行普查，得到有效的控制。行普查，得到有效的控制。行普查，得到有效的控制。行普查，得到有效的控制。Your company sloganYour company sloganPreoperative nursing key pointsPreoperative nursing key points术前护理要点术前护理要点Observe the changes
29、of the disease closely,strengthen the Observe the changes of the disease closely,strengthen the Observe the changes of the disease closely,strengthen the Observe the changes of the disease closely,strengthen the psychological nursing,prevent the blood pressure rise,cause psychological nursing,preven
30、t the blood pressure rise,cause psychological nursing,prevent the blood pressure rise,cause psychological nursing,prevent the blood pressure rise,cause the brain AVM rupture hemorrhagethe brain AVM rupture hemorrhagethe brain AVM rupture hemorrhagethe brain AVM rupture hemorrhage 密切观察病情变化，加强心理护理，防止引
31、起血压升高，诱发脑密切观察病情变化，加强心理护理，防止引起血压升高，诱发脑密切观察病情变化，加强心理护理，防止引起血压升高，诱发脑密切观察病情变化，加强心理护理，防止引起血压升高，诱发脑AVMAVMAVMAVM破破破破裂出血裂出血裂出血裂出血Improve all kinds of preoperative examination,is conducive Improve all kinds of preoperative examination,is conducive Improve all kinds of preoperative examination,is conducive Im
32、prove all kinds of preoperative examination,is conducive to the smooth operation of the operationto the smooth operation of the operationto the smooth operation of the operationto the smooth operation of the operation 完善各种术前检查，有利于手术的顺利进行完善各种术前检查，有利于手术的顺利进行完善各种术前检查，有利于手术的顺利进行完善各种术前检查，有利于手术的顺利进行Your c
33、ompany sloganYour company sloganPostoperative nursing pointsPostoperative nursing points术后护理要点术后护理要点Observe the changes of the disease,monitor Observe the changes of the disease,monitor consciousness,pupil,blood pressure,respiration,consciousness,pupil,blood pressure,respiration,body movement langua
34、ge function and Nerve functionbody movement language function and Nerve function 密切观察病情变化，监测意识、瞳孔、血压、呼吸、肢体活动、语言密切观察病情变化，监测意识、瞳孔、血压、呼吸、肢体活动、语言密切观察病情变化，监测意识、瞳孔、血压、呼吸、肢体活动、语言密切观察病情变化，监测意识、瞳孔、血压、呼吸、肢体活动、语言功能及神经功能功能及神经功能功能及神经功能功能及神经功能To strengthen the symptoms of nursing,to discover To strengthen the sym
35、ptoms of nursing,to discover and prevent the occurrence of complications,to avoid and prevent the occurrence of complications,to avoid irreversible neurological dysfunctionirreversible neurological dysfunction.加强症状护理，及时发现和预防并发症的发生，避免出现不可逆的神加强症状护理，及时发现和预防并发症的发生，避免出现不可逆的神加强症状护理，及时发现和预防并发症的发生，避免出现不可逆的神
36、加强症状护理，及时发现和预防并发症的发生，避免出现不可逆的神经功能障碍经功能障碍经功能障碍经功能障碍Your company sloganYour company sloganTreatment of complications并发症的处理并发症的处理Cerebral vascular spasm:preoperative application of Cerebral vascular spasm:preoperative application of anti vascular spasm drugs,postoperative relief in anti vascular spasm
37、drugs,postoperative relief in patients with irritability,to give nerve sedationpatients with irritability,to give nerve sedation 脑血管痉挛脑血管痉挛脑血管痉挛脑血管痉挛:术前应用抗血管痉挛药物，术后缓解患者烦躁，给予神经术前应用抗血管痉挛药物，术后缓解患者烦躁，给予神经术前应用抗血管痉挛药物，术后缓解患者烦躁，给予神经术前应用抗血管痉挛药物，术后缓解患者烦躁，给予神经镇静镇静镇静镇静Symptomatic intracranial hemorrhage,postop
38、erative Symptomatic intracranial hemorrhage,postoperative timely application of dehydration,timely application of dehydration,hemostatichemostatic drugs,drugs,close observation of consciousness,pupil,physical close observation of consciousness,pupil,physical activity and vital signsactivity and vita
39、l signs 症状性颅内出血：术后按时应用脱水、止血药物，严密观察神志、瞳症状性颅内出血：术后按时应用脱水、止血药物，严密观察神志、瞳症状性颅内出血：术后按时应用脱水、止血药物，严密观察神志、瞳症状性颅内出血：术后按时应用脱水、止血药物，严密观察神志、瞳孔、肢体活动及生命体征孔、肢体活动及生命体征孔、肢体活动及生命体征孔、肢体活动及生命体征Your company sloganYour company sloganTreatment of complicationsNeurological dysfunction:functional abnormalities Neurological d
40、ysfunction:functional abnormalities should be promptly expanded blood vessels and nerve should be promptly expanded blood vessels and nerve nutrition therapy,the condition of stable after nutrition therapy,the condition of stable after hyperbaric oxygen therapyhyperbaric oxygen therapy 神经功能障碍：功能异常者应
41、及时扩血管及神经营养治疗，病情平稳神经功能障碍：功能异常者应及时扩血管及神经营养治疗，病情平稳神经功能障碍：功能异常者应及时扩血管及神经营养治疗，病情平稳神经功能障碍：功能异常者应及时扩血管及神经营养治疗，病情平稳后行高压氧治疗后行高压氧治疗后行高压氧治疗后行高压氧治疗Epilepsy:intracranial hemorrhage,cerebral Epilepsy:intracranial hemorrhage,cerebral vasospasm,cerebral ischemia,contrast agent toxicity vasospasm,cerebral ischemia,c
42、ontrast agent toxicity can be induced,postoperative epilepsycan be induced,postoperative epilepsy 癫痫：颅内出血、脑血管痉挛、脑缺血、造影剂毒性均可诱发术中、癫痫：颅内出血、脑血管痉挛、脑缺血、造影剂毒性均可诱发术中、癫痫：颅内出血、脑血管痉挛、脑缺血、造影剂毒性均可诱发术中、癫痫：颅内出血、脑血管痉挛、脑缺血、造影剂毒性均可诱发术中、术后癫痫术后癫痫术后癫痫术后癫痫Your company sloganYour company sloganTreatment of complicationsTh
43、e normal cerebral perfusion pressure breakthrough The normal cerebral perfusion pressure breakthrough syndrome or circulatory breakthrough syndrome:the syndrome or circulatory breakthrough syndrome:the incidence is lower,but the consequences are seriousincidence is lower,but the consequences are ser
44、ious.正常脑灌注压突破综合征或循环突破综合征：发生率较低，但后果严正常脑灌注压突破综合征或循环突破综合征：发生率较低，但后果严正常脑灌注压突破综合征或循环突破综合征：发生率较低，但后果严正常脑灌注压突破综合征或循环突破综合征：发生率较低，但后果严重重重重Your company sloganYour company sloganmental nursingPatients with nervous and emotional changes may Patients with nervous and emotional changes may cause abnormal blood ve
45、ssel rupture,so the whole cause abnormal blood vessel rupture,so the whole process of psychological care should be run through process of psychological care should be run through the whole process of treatment.the whole process of treatment.心理护理：心理护理：心理护理：心理护理：患者由于紧张害怕等心理及情绪变化有可能会导致畸形血管团破裂，患者由于紧张害怕等心理及情绪变化有可能会导致畸形血管团破裂，患者由于紧张害怕等心理及情绪变化有可能会导致畸形血管团破裂，患者由于紧张害怕等心理及情绪变化有可能会导致畸形血管团破裂，因此心理护理应贯穿于治疗的全过程。因此心理护理应贯穿于治疗的全过程。因此心理护理应贯穿于治疗的全过程。因此心理护理应贯穿于治疗的全过程。Your company sloganYour company slogan