뇌동정맥기형의 수술합병증 : 297예의 후향적 분석

Abstract

To analyze the complications following surgical resection of cerebral arteriovenous malformations (AVMs) and to improve the surgical outcomes, we reviewed 297 consecutive patients who had undergone surgical excision of AVM at Yonsei University between June 1975 and July 2004. The patients' ages ranged from 2 to 68 with a mean age of 29 years. The series included 182 males (61.3%) and 115 females (38.5%). The most common presenting symptom was hemorrhage (228 patients, 76.8%). And others were seizure (45 patients, 15.2%), hemorrhage with seizure (12 patients, 4.1%), focal deficit (3 patients, 1.0%), headache (4 patients, 1.3%) and incidental (5 patients, 1.6%). The locations of AVMs were cerebral convexity (220 patients, 74%；46 frontal, 68 parietal, 77 temporal, 29 occipital), callosal (28 patients, 9.4%), sylvian (11 patients, 3.7%), rolandic (8 patients, 2.7%), basal ganglia and thalamus (11patients, 3.7%), cerebellum (18 patients, 6.1%) and one patient had brain stem lesion (0.3%). Postoperative rebleeding and the incomplete excision (12 and 9 patients each) were the major surgical complications, followed by postoperative epilepsy (5 patients), normal perfusion pressure breakthrough (3 patients), and infection (2 patients). The outcome was classified into good for the patients who returned to their previous jobs with or without neurological deficits, fair for the patients who were unable to return to work but performed daily activities independently with minor deficits, and poor for the patients who were performing dependent daily activities with major deficits. The average follow-up period was 4.2 years. The overall outcome of surgery was considered good in 233 patients (75.0%), fair in 51 patients (17.2%), poor in 15 patients (5.1%) and 8 patients (2.7%) were died. The Spetzler-Martin grading system correlated well with the difficulty of surgery. No morbidity resulted from resection of Grade I AVMs；the percentage with unfavorable outcome was 8.1% in Grade II, 9.6% in Grade III, and 28.6% for those with Grade IV. Initial insult (14 patients) and rebleeding (4 patients) were the major causes of unfavorable outcome. Prevention of postoperative hemorrhage following meticulous hemostasis and complete excision and prevention of hemodynamic complications would result in a favorable outcome after surgery for cerebral AVM.