A Giant Arteriovenous Malformation : Report of a Case that Showed Dramatic Neurological Improvement after Multi-staged Emboilization prior to the Surgical Removal of Malformation

本症例は右側頭頭頂後頭葉を占拠する巨大脳動静脈奇形で,著しい慢性脳虚血を伴い,頻回の痙攣発作と痴呆などの進行性神経脱落症候を呈した.全摘出はきわめて危険かつ困難であり,さらにCTにて大脳皮質下に広範な石灰化を認め,症状改善も困難と考えられていた.新開発のガイドワイヤーにより超選択的カテーテル挿入が可能となり,術前staged embolizationと術中embolizationの併用によりnormal perfusion pressure breakthroughの合併なく全摘出術に成功した.さらに術前embolizationの過程で,shunt flowの軽減に伴い神経脱落症候が劇的に改善したことも注目に値する.The authors describe a huge arteriovenous malformation (AVM) in the right temporo-parieto-occipital lobes that was successfully removed after a multi-staged embolization of the feeding arteries. The patient, a 54-year-old housewife, had presented uncontrolable epilepsy, progressive dementia, hemianopsia, hemiparesis, and hemisensory impairment of the left side. Angiography revealed a huge AVM mainly being nourished by the following sources : the parieto-occipital arteries of the posterior cerebra] artery, the temporal branches of the middle cerebral artery and dura] branches from the external carotid and vertebral arteries. Further, the cortical draining veins over the entire hemisphere were markedly, dilated, and the superior sagittal and straight sinuses visualized poorly, probably due to the congestion in the venous circulation caused by the arteriovenous shunt. CT scans also revealed multiple, club-like calcification in the parietal and frontal subcortical regions, indicating chronic brain ischemia caused by the remarkable arterial s_teal and/or venous hypertension. . Preoperative super-selective embolization was done in four sessions, using newly developed, low-friction, high -torque guide wires. and this resulted in a dramatic neurological improvement, especially with regard to the dementia. Then, following intraoperative embolization of the remaining feeding arteries, the AVM was success-fully removed. The patient tolerated these procedures well without hemodynamic complications, and after a few months of rehabilitation, she resumed her normal life

術前塞栓術により劇的に神経脱落症候が改善し全摘出に成功した巨大脳動静脈奇形の1症例

本症例は右側頭頭頂後頭葉を占拠する巨大脳動静脈奇形で,著しい慢性脳虚血を伴い,頻回の痙攣発作と痴呆などの進行性神経脱落症候を呈した.全摘出はきわめて危険かつ困難であり,さらにCTにて大脳皮質下に広範な石灰化を認め,症状改善も困難と考えられていた.新開発のガイドワイヤーにより超選択的カテーテル挿入が可能となり,術前staged embolizationと術中embolizationの併用によりnormal perfusion pressure breakthroughの合併なく全摘出術に成功した.さらに術前embolizationの過程で,shunt flowの軽減に伴い神経脱落症候が劇的に改善したことも注目に値する.The authors describe a huge arteriovenous malformation (AVM) in the right temporo-parieto-occipital lobes that was successfully removed after a multi-staged embolization of the feeding arteries. The patient, a 54-year-old housewife, had presented uncontrolable epilepsy, progressive dementia, hemianopsia, hemiparesis, and hemisensory impairment of the left side. Angiography revealed a huge AVM mainly being nourished by the following sources : the parieto-occipital arteries of the posterior cerebra] artery, the temporal branches of the middle cerebral artery and dura] branches from the external carotid and vertebral arteries. Further, the cortical draining veins over the entire hemisphere were markedly, dilated, and the superior sagittal and straight sinuses visualized poorly, probably due to the congestion in the venous circulation caused by the arteriovenous shunt. CT scans also revealed multiple, club-like calcification in the parietal and frontal subcortical regions, indicating chronic brain ischemia caused by the remarkable arterial s_teal and/or venous hypertension. . Preoperative super-selective embolization was done in four sessions, using newly developed, low-friction, high -torque guide wires. and this resulted in a dramatic neurological improvement, especially with regard to the dementia. Then, following intraoperative embolization of the remaining feeding arteries, the AVM was success-fully removed. The patient tolerated these procedures well without hemodynamic complications, and after a few months of rehabilitation, she resumed her normal life

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study

Objectives To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.Design Retrospective study.Setting Six hundred and thirty-one primary care institutions in Japan.Participants Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.Primary and secondary outcome measures Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3–6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1–25 points).Results In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.Conclusions The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era