脑动静脉畸形-医药类课件1.ppt

1、CEREBRALARTERIOVENOUS MALFORMATIONSAVM:a TLA for the CNSC E R E B R A L A V M:a T L A f o r t h e C N SIncidencen0.52%at autopsynSlight male preponderance(1.09 to 1.94)nCongenital lesions(although rarely familial)I n c i d e n c e 0.5 2%a t a u t o p s yEmbryologynFirst half of third week of gestati

2、onepiblastic cells migrate to form mesodermmesodermal cells differentiate to arterial and venous vessels on the surface of the embryonic nervous systemE mb r y o l o g y F i r s t h a l f o f t h i r d EmbryologynFirst half of third week of gestationepiblastic cells migrate to form mesodermmesoderma

3、l cells differentaite to arterial and venous vessels on the surface of the embryonic nervous systemnSeventh gestational weekvessels sprout branches&penetrate developing brainreach the gray-white interface,either loop back to pial surface or traverse entire neural tube,thus epicerebral&transcerebral

4、circneventually connect arterial and venous systems by around the twelfth week E mb r y o l o g y F i r s t h a l f o f t h i r d Pathology&Pathophysiologynabsence of normal capillary systemP a t h o l o g y&P a t h o p h y s i o l o g y a b sPathology&Pathophysiologynabsence of normal capillary sys

5、temnusual function displacedP a t h o l o g y&P a t h o p h y s i o l o g y a b sPathology&Pathophysiologynabsence of normal capillary systemnusual function displacednasymptomatic at birthP a t h o l o g y&P a t h o p h y s i o l o g y a b sPathology&Pathophysiologynabsence of normal capillary syste

6、mnusual function displacednasymptomatic at birthnvessels change with timenmay develop aneurysmsP a t h o l o g y&P a t h o p h y s i o l o g y a b sparenchymal changes within and around the lesionPathology&Pathophysiologynabsence of normal capillary systemnusual function displacednasymptomatic at bi

7、rthnvessels change with timenmay develop aneurysmsp a r e n c h y ma l c h a n g e s w i t h i n a n dparenchymal changes within and around the lesionsite frequency is proportional to brain volumePathology&Pathophysiologynabsence of normal capillary systemnusual function displacednasymptomatic at bi

8、rthnvessels change with timenmay develop aneurysmsp a r e n c h y ma l c h a n g e s w i t h i n a n dClinical presentationn95%have symptoms by age of 70 yearsC l i n i c a l p r e s e n t a t i o n 9 5%h a v e Clinical presentationn95%have symptoms by age of 70 yearsnpeak presentation second to fou

9、rth decadeC l i n i c a l p r e s e n t a t i o n 9 5%h a v e Clinical presentationn95%have symptoms by age of 70 yearsnpeak presentation second to fourth decadehigh output failure,neonate,vein of Galenhydrocephalus,first decadeheadache,hemorrhage,seizures,2nd&3rdC l i n i c a l p r e s e n t a t i

10、o n 9 5%h a v e Clinical presentationnfactors contributing to symptomsvessel walls,flow and pressuresC l i n i c a l p r e s e n t a t i o n f a c t o r s cClinical presentationnfactors contributing to symptomsvessel walls,flow and pressuresenlargement and encroachmentC l i n i c a l p r e s e n t a

11、 t i o n f a c t o r s cClinical presentationnfactors contributing to symptomsvessel walls,flow and pressuresenlargement and encroachmentdural sinusesC l i n i c a l p r e s e n t a t i o n f a c t o r s cClinical presentationnfactors contributing to symptomsvessel walls,flow and pressuresenlargemen

12、t and encroachmentdural sinusesischaemiaC l i n i c a l p r e s e n t a t i o n f a c t o r s cClinical presentationnfactors contributing to symptomsvessel walls,flow and pressuresenlargement and encroachmentdural sinusesischaemiacardiac outputC l i n i c a l p r e s e n t a t i o n f a c t o r s cC

13、linical presentationDeficits10%Headaches10%Seizures30%Hemorrhage50%C l i n i c a l p r e s e n t a t i o nHemorrhagenAVMrupture not a function of sizenAneurysmrupture related to aneurysm sizeH e mo r r h a g e A V MA n e u r y s mHemorrhagenAVMrupture not a function of sizeno marked increase with ex

14、ercise,pregnancy,traumanAneurysmrupture related to aneurysm sizeincrease with trauma exercise,end pregnancyH e mo r r h a g e A V MA n e u r y s mHemorrhagenAVMrupture not a function of sizeno marked increase with exercise,pregnancy,traumaarteriovenous,therefore less severenAneurysmrupture related t

15、o aneurysm sizeincrease with trauma exercise,end pregnancyarterial,therefore more severeH e mo r r h a g e A V MA n e u r y s mHemorrhagenAVMrupture not a function of sizeno marked increase with exercise,pregnancy,traumaarteriovenous,therefore less severemortality 6 to 13.6%nAneurysmrupture related

16、to aneurysm sizeincrease with trauma exercise,end pregnancyarterial,therefore more severemortality 30-50%H e mo r r h a g e A V MA n e u r y s mHemorrhagenAVMrupture not a function of sizeno marked increase with exercise,pregnancy,traumaarteriovenous,therefore less severemortality 6 to 13.6%lower re

17、bleed mortality rate(1%)nAneurysmrupture related to aneurysm sizeincrease with trauma exercise,end pregnancyarterial,therefore more severemortality 30-50%higher rebleed mortality rate(13%)H e mo r r h a g e A V MA n e u r y s mHemorrhagenAVMrupture not a function of sizeno marked increase with exerc

18、ise,pregnancy,traumaarteriovenous,therefore less severemortality 6 to 13.6%lower rebleed mortality rate(1%)vasospasm rarenAneurysmrupture related to aneurysm sizeincrease with trauma exercise,end pregnancyarterial,therefore more severemortality 30-50%higher rebleed mortality rate(13%)vasospasm commo

19、nH e mo r r h a g e A V MA n e u r y s mHemorrhage-AVMnNonetheless,risk of major,incapacitating,or fatal hemorrhage in untreated lesion is 40 to 50%H e mo r r h a g e -A V MN o n e t h e l e s s,rHemorrhage-AVMnNonetheless,risk of major,incapacitating,or fatal hemorrhage in untreated lesion is 40 to

20、 50%nYearly risk of initial hemorrhage 3%nRebleed in first subsequent year 6-18%,reducing to 3%again thereafternPediatric prognosis worse than adult H e mo r r h a g e -A V MN o n e t h e l e s s,rSpetzler&Martin Grading SystemCriteriaScoreSize of Nidus Small(6cm)3Eloquence of Adjacent Brain No0Yes1

21、Deep Vascular Component No0Yes1S p e t z l e r&Ma r t i n G r a d i n g S y s tTreatment OptionsHSurgical ResectionT r e a t me n t O p t i o n s S u r g i c a l R e s eTreatment OptionsHSurgical ResectionHEndovascular EmbolisationT r e a t me n t O p t i o n s S u r g i c a l R e s eTreatment Optio

22、nsHSurgical ResectionHEndovascular EmbolisationHStereotatic RadiosurgeryT r e a t me n t O p t i o n s S u r g i c a l R e s eTreatment OptionsHSurgical ResectionHEndovascular EmbolisationHStereotatic RadiosurgeryHMultimodal TherapyT r e a t me n t O p t i o n s S u r g i c a l R e s eTreatment Opti

23、onsHSurgical ResectionHEndovascular EmbolisationHStereotatic RadiosurgeryHMultimodal TherapyHConservative ManagementT r e a t me n t O p t i o n s S u r g i c a l R e s eNormal Perfusion Pressure Breakthrough TheoryR.F.Spetzler et alN o r ma l P e r f u s i o n P r e s s u r e B r e aNormal perfusio

24、n pressure breakthrough theoryLoss of autoregulation and carbon dioxide reactivity in presence of large arteriovenous malformation.N o r ma l p e r f u s i o n p r e s s u r e b r e aNormal perfusion pressure breakthrough theoryLoss of autoregulation and carbon dioxide reactivity in presence of larg

25、e arteriovenous malformation.Normal hemispheric vessels are chronically maximally dilated to attempt to divert flow from the AVMN o r ma l p e r f u s i o n p r e s s u r e b r e aNormal perfusion pressure breakthrough theoryLoss of autoregulation and carbon dioxide reactivity in presence of large a

26、rteriovenous malformation.Normal hemispheric vessels are chronically maximally dilated to attempt to divert flow from the AVMObliteration of the AVM diverts all flow to these maximally dilated vessels which have lost their normal control mechanismsN o r ma l p e r f u s i o n p r e s s u r e b r e a

27、Normal perfusion pressure breakthrough theoryLoss of autoregulation and carbon dioxide reactivity in presence of large arteriovenous malformation.Normal hemispheric vessels are chronically maximally dilated to attempt to divert flow from the AVMObliteration of the AVM diverts all flow to these maxim

28、ally dilated vessels which have lost their normal control mechanismsResults in loss of protection of the capillary bed,with edema and hemorrhageN o r ma l p e r f u s i o n p r e s s u r e b r e aArterial inflowMathematical ModelsA r t e r i a l i n f l o w Ma t h e ma t i c a l MoArterial inflowNidusMathematical ModelsA r t e r i a l i n f l o w Ma t h e ma t i c a l MoArterial inflowNidusVenous OutflowMathematical ModelsA r t e r i a l i n f l o w Ma t h e ma t i c a l MoAnaesthesia TechniqueA n a e s t h e s i a T e c h n i q u e