Embolization of Arteriovenous Fistula after Radiosurgery for Multiple Cerebral Arteriovenous Malformations

多發性腦動靜脈畸形或動靜脈瘻管非常少見，這罕見的多發性血管畸形即使以血管攝影有時也不易同時診斷。本文報告一例因頭痛及頭部雜音求診的37歲男性患者，經檢查診斷患有左側顳葉腦動靜脈畸形合併擴大彎曲及快速的靜脈血流。此腦動靜脈畸接受加馬刀放射手術治療，術後3年追蹤期間磁振造影顯示動靜脈畸形逐漸變小，但擴大彎曲的快速靜脈血流仍在，且病患症狀並未獲得明顯改善。此時的追蹤血管攝影發現另有一動靜脈瘻管於同側大腦顳葉深部，三年前此瘻廔管因與擴大彎曲的靜脈血管及腦動靜脈畸重疊而被忽視。針對此動靜脈瘻管我們使用可分離式線圈經血管內栓塞治療成功地將此瘻管堵住，病患並獲得立即症狀緩解。由此例經驗顯見有時使用微小導管做超選擇血管攝影是必須的，它有利於檢視瘻管是否與腦動靜脈畸形並存，特別是針對腦動靜脈畸形合併擴大彎曲及快速靜脈血流及部份治療後症狀仍持續的患者，尤具診療價質。此外以微小導管做超選擇血管攝影的同時，如因病情需要，亦能提供立即栓塞治療腦動靜脈畸形的瘻管部分；之後以加馬刀放射手術治療剩餘的動靜脈畸形部分，應可加速放射手術療效及改善神經症狀並減少治療後的出血機會。

關鍵字

動靜脈畸形；動靜脈畸瘻管；栓塞；放射外科

並列摘要

Cerebral arteriovenous malformation (CAVM) associated with arteriovenous fistula (AVF) is rare. It may be difficult to identify hemodynamic details of mixed CAVM and AVF, even when using x-ray cerebral angiography (digital subtraction angiography). We report on a 37-year-old male patient with headache that led to an initial diagnosis of deep frontotemporal CAVM. The first DSA revealed engorged, tortuous, and high-flow venous drainage in addition to clusters of vasculature niduses. The patient was initially treated using γ-knife radiosurgery (GKRS), which resulted in partial nidus obliteration, documented by a series of follow-up magnetic resonance imaging (MRI). However, the high-flow venous drainage remained, seen on MRI as engorged venous pouches. Clinically, the patient was bothered by persistent headache and bruits after GKRS. Follow-up DSA 3 years after GKRS confirmed a small remnant CAVM nidus and a nearby AVF, separated from and lateral to the original CAVM nidus in the ipsilateral deep temporal lobe. When the initial DSA was reviewed, it revealed that the AVF was difficult to define because of superimposition of the nidus and engorged drainage vessels. Embolization of the AVF using electrodetachable coils resulted in total occlusion of the AVF. The patient's symptoms resolved immediately after embolization. This case suggests that superselective angiography using a microcatheter may be necessary for the initial diagnosis of CAVM associated with AVF with high-flow and engorged venous drainage. For CAVM patients with persistent symptoms after radiosurgery and engorged venous drainage when CAVM is expected to be cured, a microcatheter and superselective endovascular approach may offer diagnosis. Immediate embolization for associated AVF in the same angiographic session may thereby improve neurologic deficits and reduce hemorrhagic risk during the latency after GKRS.

並列關鍵字

arteriovenous malformation ； arteriovenous fistula ； embolization ； radiosurgery

國際替代計量

Embolization of Arteriovenous Fistula after Radiosurgery for Multiple Cerebral Arteriovenous Malformations

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