腦動靜脈畸形課件整理

Incidence0.52%atautopsySlightmalepreponderance(1.09to1.94)Congenitallesions(althoughrarelyfamilial)Incidence0.52%atautopsy1EmbryologyFirsthalfofthirdweekofgestationepiblasticcellsmigratetoformmesodermmesodermalcellsdifferentiatetoarterialandvenousvesselsonthesurfaceoftheembryonicnervoussystemEmbryologyFirsthalfofthird2EmbryologyFirsthalfofthirdweekofgestationepiblasticcellsmigratetoformmesodermmesodermalcellsdifferentaitetoarterialandvenousvesselsonthesurfaceoftheembryonicnervoussystemSeventhgestationalweekvesselssproutbranches&penetratedevelopingbrainreachthegray-whiteinterface,eitherloopbacktopialsurfaceortraverseentireneuraltube,thusepicerebral&transcerebralcirc'neventuallyconnectarterialandvenoussystemsbyaroundthetwelfthweekEmbryologyFirsthalfofthird3Pathology&PathophysiologyabsenceofnormalcapillarysystemPathology&Pathophysiologyabs4Pathology&PathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedPathology&Pathophysiologyabs5Pathology&PathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthPathology&Pathophysiologyabs6Pathology&PathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthvesselschangewithtimemaydevelopaneurysmsPathology&Pathophysiologyabs7parenchymalchangeswithinandaroundthelesionPathology&Pathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthvesselschangewithtimemaydevelopaneurysmsparenchymalchangeswithinand8parenchymalchangeswithinandaroundthelesionsitefrequencyisproportionaltobrainvolumePathology&Pathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthvesselschangewithtimemaydevelopaneurysmsparenchymalchangeswithinand9Clinicalpresentation95%havesymptomsbyageof70yearsClinicalpresentation95%have10Clinicalpresentation95%havesymptomsbyageof70yearspeakpresentationsecondtofourthdecadeClinicalpresentation95%have11Clinicalpresentation95%havesymptomsbyageof70yearspeakpresentationsecondtofourthdecadehighoutputfailure,neonate,veinofGalenhydrocephalus,firstdecadeheadache,hemorrhage,seizures,2nd&3rdClinicalpresentation95%have12Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresClinicalpresentationfactorsc13Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentClinicalpresentationfactorsc14Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentduralsinusesClinicalpresentationfactorsc15Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentduralsinusesischaemiaClinicalpresentationfactorsc16Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentduralsinusesischaemiacardiacoutputClinicalpresentationfactorsc17ClinicalpresentationClinicalpresentation18HemorrhageAVMrupturenotafunctionofsizeAneurysmrupturerelatedtoaneurysmsizeHemorrhageAVMAneurysm19HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaAneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyHemorrhageAVMAneurysm20HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelesssevereAneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoresevereHemorrhageAVMAneurysm21HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelessseveremortality6to13.6%Aneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoreseveremortality30-50%HemorrhageAVMAneurysm22HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelessseveremortality6to13.6%lowerrebleedmortalityrate(1%)Aneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoreseveremortality30-50%higherrebleedmortalityrate(13%)HemorrhageAVMAneurysm23HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelessseveremortality6to13.6%lowerrebleedmortalityrate(1%)vasospasmrareAneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoreseveremortality30-50%higherrebleedmortalityrate(13%)vasospasmcommonHemorrhageAVMAneurysm24Hemorrhage-AVMNonetheless,riskofmajor,incapacitating,orfatalhemorrhageinuntreatedlesionis40to50%Hemorrhage-AVMNonetheless,r25Hemorrhage-AVMNonetheless,riskofmajor,incapacitating,orfatalhemorrhageinuntreatedlesionis40to50%Yearlyriskofinitialhemorrhage~3%Rebleedinfirstsubsequentyear6-18%,reducingto~3%againthereafterPediatricprognosisworsethanadultHemorrhage-AVMNonetheless,r26Spetzler&MartinGradingSystemCriteriaScoreSizeofNidus

Small(<3cm)1Medium(3-6cm)2Large(>6cm)3EloquenceofAdjacentBrain

No0Yes1DeepVascularComponent

No0Yes1Spetzler&MartinGradingSyst27TreatmentOptionsSurgicalResectionTreatmentOptionsSurgicalRese28TreatmentOptionsSurgicalResectionEndovascularEmbolisationTreatmentOptionsSurgicalRese29TreatmentOptionsSurgicalResectionEndovascularEmbolisationStereotaticRadiosurgeryTreatmentOptionsSurgicalRese30TreatmentOptionsSurgicalResectionEndovascularEmbolisationStereotaticRadiosurgeryMultimodalTherapyTreatmentOptionsSurgicalRese31TreatmentOptionsSurgicalResectionEndovascularEmbolisationStereotaticRadiosurgeryMultimodalTherapyConservativeManagementTreatmentOptionsSurgicalRese32NormalPerfusionPressureBreakthroughTheoryR.F.SpetzleretalNormalPerfusionPressureBrea33NormalperfusionpressurebreakthroughtheoryLossofautoregulationandcarbondioxidereactivityinpresenceoflargearteriovenousmalformation.Normalperfusionpressurebrea34NormalperfusionpressurebreakthroughtheoryLossofautoregulationandcarbondioxidereactivityinpresenceoflargearteriovenousmalformation.NormalhemisphericvesselsarechronicallymaximallydilatedtoattempttodivertflowfromtheAVMNormalperfusionpressurebrea35NormalperfusionpressurebreakthroughtheoryLossofautoregulationandcarbondioxidereactivityinpresenceoflargearteriovenousmalformation.NormalhemisphericvesselsarechronicallymaximallydilatedtoattempttodivertflowfromtheAVMObliterationoftheAVMdivertsallflowtothesemaximallydilatedvesselswhichhavelosttheirnormalcontrolmechanismsNormalperfusionpressurebrea36NormalperfusionpressurebreakthroughtheoryLossofautoregulationandcarbondioxidereactivityinpresenceoflargearteriovenousmalformation.NormalhemisphericvesselsarechronicallymaximallydilatedtoattempttodivertflowfromtheAVMObliterationoftheAVMdivertsallflowtothesemaximallydilatedvesselswhichhavelosttheirnormalcontrolmechanismsResultsinlossofprotectionofthecapillarybed,withedemaandhemorrhageNormalperfusionpressurebrea37ArterialinflowMathematicalModelsArterialinflowMathematicalMo38ArterialinflowNidusMathematicalModelsArterialinflowMathematicalMo39ArterialinflowNidusVenousOutflowMathematicalModelsArterialinflowMathematicalMo40AnaesthesiaTechniqueAnaesthesiaTechnique41謝謝騎封篙尊慈榷灶琴村店矣墾桂乖新壓胚奠倘擅寞僥蝕麗鑒晰溶廷籮侶郎蟲林森-消化系統(tǒng)疾病的癥狀體征與檢查林森-消化系統(tǒng)疾病的癥狀體征與檢查謝謝騎封篙尊慈榷灶琴村店矣墾桂乖新壓胚奠倘擅寞僥蝕麗鑒晰溶廷42騎封篙尊慈榷灶琴村店矣墾桂乖新壓胚奠倘擅寞僥蝕麗鑒晰溶廷籮侶郎蟲林森-消化系統(tǒng)疾病的癥狀體征與檢查林森-消化系統(tǒng)疾病的癥狀體征與檢查騎封篙尊慈榷灶琴村店矣墾桂乖新壓胚奠倘擅寞僥蝕麗鑒晰溶廷籮侶43Incidence0.52%atautopsySlightmalepreponderance(1.09to1.94)Congenitallesions(althoughrarelyfamilial)Incidence0.52%atautopsy44EmbryologyFirsthalfofthirdweekofgestationepiblasticcellsmigratetoformmesodermmesodermalcellsdifferentiatetoarterialandvenousvesselsonthesurfaceoftheembryonicnervoussystemEmbryologyFirsthalfofthird45EmbryologyFirsthalfofthirdweekofgestationepiblasticcellsmigratetoformmesodermmesodermalcellsdifferentaitetoarterialandvenousvesselsonthesurfaceoftheembryonicnervoussystemSeventhgestationalweekvesselssproutbranches&penetratedevelopingbrainreachthegray-whiteinterface,eitherloopbacktopialsurfaceortraverseentireneuraltube,thusepicerebral&transcerebralcirc'neventuallyconnectarterialandvenoussystemsbyaroundthetwelfthweekEmbryologyFirsthalfofthird46Pathology&PathophysiologyabsenceofnormalcapillarysystemPathology&Pathophysiologyabs47Pathology&PathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedPathology&Pathophysiologyabs48Pathology&PathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthPathology&Pathophysiologyabs49Pathology&PathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthvesselschangewithtimemaydevelopaneurysmsPathology&Pathophysiologyabs50parenchymalchangeswithinandaroundthelesionPathology&Pathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthvesselschangewithtimemaydevelopaneurysmsparenchymalchangeswithinand51parenchymalchangeswithinandaroundthelesionsitefrequencyisproportionaltobrainvolumePathology&Pathophysiologyabsenceofnormalcapillarysystemusualfunctiondisplacedasymptomaticatbirthvesselschangewithtimemaydevelopaneurysmsparenchymalchangeswithinand52Clinicalpresentation95%havesymptomsbyageof70yearsClinicalpresentation95%have53Clinicalpresentation95%havesymptomsbyageof70yearspeakpresentationsecondtofourthdecadeClinicalpresentation95%have54Clinicalpresentation95%havesymptomsbyageof70yearspeakpresentationsecondtofourthdecadehighoutputfailure,neonate,veinofGalenhydrocephalus,firstdecadeheadache,hemorrhage,seizures,2nd&3rdClinicalpresentation95%have55Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresClinicalpresentationfactorsc56Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentClinicalpresentationfactorsc57Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentduralsinusesClinicalpresentationfactorsc58Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentduralsinusesischaemiaClinicalpresentationfactorsc59Clinicalpresentationfactorscontributingtosymptomsvesselwalls,flowandpressuresenlargementandencroachmentduralsinusesischaemiacardiacoutputClinicalpresentationfactorsc60ClinicalpresentationClinicalpresentation61HemorrhageAVMrupturenotafunctionofsizeAneurysmrupturerelatedtoaneurysmsizeHemorrhageAVMAneurysm62HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaAneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyHemorrhageAVMAneurysm63HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelesssevereAneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoresevereHemorrhageAVMAneurysm64HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelessseveremortality6to13.6%Aneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoreseveremortality30-50%HemorrhageAVMAneurysm65HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelessseveremortality6to13.6%lowerrebleedmortalityrate(1%)Aneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoreseveremortality30-50%higherrebleedmortalityrate(13%)HemorrhageAVMAneurysm66HemorrhageAVMrupturenotafunctionofsizenomarkedincreasewithexercise,pregnancy,traumaarteriovenous,thereforelessseveremortality6to13.6%lowerrebleedmortalityrate(1%)vasospasmrareAneurysmrupturerelatedtoaneurysmsizeincreasewithtraumaexercise,endpregnancyarterial,thereforemoreseveremortality30-50%higherrebleedmortalityrate(13%)vasospasmcommonHemorrhageAVMAneurysm67Hemorrhage-AVMNonetheless,riskofmajor,incapacitating,orfatalhemorrhageinuntreatedlesionis40to50%Hemorrhage-AVMNonetheless,r68Hemorrhage-AVMNonetheless,riskofmajor,incapacitating,orfatalhemorrhageinuntreatedlesionis40to50%Yearlyriskofinitialhemorrhage~3%Rebleedinfirstsubsequentyear6-18%,reducingto~3%againthereafterPediatricprognosisworsethanadultHemorrhage-AVMNonetheless,r69Spetzler&MartinGradingSystemCriteriaScoreSizeofNidus

Small(<3cm)1Medium(3-6cm)2Large(>6cm)3EloquenceofAdjacentBrain

No0Yes1DeepVascularComponent

No0Yes1Spetzler&MartinGradingSyst70TreatmentOptionsSurgicalResectionTreatmentOptionsSurgicalRese71TreatmentOptionsSurgicalResectionEndovascularEmbolisationTreatmentOptionsSurgicalRese72TreatmentOptionsSurgicalResectionEndovascularEmbolisationStereotaticRadiosurgeryTreatmentOptionsSurgicalRese73TreatmentOptionsSurgicalResectionEndovascularEmbolisationStereotaticRadiosurgeryMultimodalTherapyTreatmentOptionsSurgicalRese74TreatmentOptionsSurgicalResectionEndovascularEmbolisationStereotaticRadiosurgeryMultimodalTherapyConservativeManagementTreatmentOptionsSurgicalRese75NormalPerfusionPressureBreakthroughTheoryR.F.SpetzleretalNormalPerfusionPressureBrea76NormalperfusionpressurebreakthroughtheoryLossofautoregulationandcarbondioxidereactivityinpresenceoflargearteriovenousmalformation.Normalperfusionpressurebrea77Normalperfusionpr