JNNP:脑海绵状血管畸形综述,治疗方法的比较

2022-03-17 网络 网络

海绵状血管畸形(CMs)是一种典型的桑椹样外观的扩张血管,发生在静脉-毛细血管床上,不干预脑实质、肌肉或弹性组织。1 2根据最新的国际血管瘤研究学会(ISSVA)对血管异常的分类,3 CMs被定义为慢

海绵状血管畸形(CMs)是一种典型的桑椹样外观的扩张血管,发生在静脉-毛细血管中,不干预脑实质、肌肉或弹性组织。根据最新的国际血管瘤研究学会(ISSVA)对血管异常的分类, CMs被定义为慢流静脉畸形。脑海绵状畸形(CCMs)有两种可能的形式:散发性和家族性。后者被认为是一种常染色体显性疾病,由负责内皮细胞间连接完整性的三个基因之一的突变引起。4个CCM代表10%⎯15%的中枢神经系统血管畸形5;大多数发生在幕上位置。临床症状通常为癫痫发作、脑内出血(ICH)和非出血性局灶性神经功能缺损。CCM治疗的目的通常是预防出血,但神经功能缺损的稳定或癫痫发作的控制是干预的另一个可能指征。已经发表了几篇关于CMs治疗的荟萃分析。然而,没有人能够将所有三种治疗方法(即手术、放射外科和观察)与大量分析的原始数据进行比较。进行荟萃分析是为了统一所有可能的治疗方案的结果,阐明其疗效,并指定与CCMs动态行为相关的因素。目的是明确定义(1)出血、(2)死亡率和(3)发病率,同时明确哪些部位(不仅脑干,还有脑叶、深部和小脑CCMs)以及性别和既往出血史是否与出血风险的高低相关。本文发表在《神经病学,神经外科学和精神病学杂志》上()。

检索PubMed、Cochrane Library、Science Direct、ISI科学网、Embase和其他来源,以确定1990年至2020年间发表的关于CCMs治疗的队列研究。遵循系统评价和荟萃分析指南的首选报告项目;纽卡斯尔-渥太华量表用于评估偏倚风险,并基于选择/结果偏倚评估局限性。使用随机效应模型计算95%CI的累积发病率。采用泊松分布模型,通过计算95%可信区间的比率,评估治疗效果较差的风险因素。纳入所有年龄段的患者,并对1990年1月至2020年12月期间发表的至少20例CCM保守治疗、外科治疗或放射外科治疗结果的患者进行分析。我们只搜索了以英文正式发表的回顾性和前瞻性研究。在多次引用同一患者的案例中,我们分析了最大/最新的队列。每个经过分析的研究都由以前未被纳入其他系列的独特受试者组成。

每种治疗方法的疗效和死亡率/死亡率

在41098人的随访中,共分析了100个队列,其中8994名患者接受了CCMs治疗。确保预防出血的有效性在外科手术中为97%,在放射外科手术中为86%,在保守治疗中为77%。放射外科手术后死亡率最低(1%),自然史系列的持续发病率最高(22%)。深部和脑干CCM与较高的出血率相关。在所有分析中,肺叶定位是一个保护因素。既往有出血史的患者再次出血的风险更高。男性是治疗后出血风险较低的保护因素。小脑和脑干CCM与治疗后出血的高风险相关。初始脑出血也与放射外科干预后出血风险较高相关(RR 1.009,95%可信区间1.002至1.017;p=0.013)。在保守治疗系列中,男性、脑叶和小脑CCMs与较低的出血风险相关,而脑干CCMs与较高的出血风险相关(RR 1.008,95%可信区间1.006至1.013;p<0.001)。初始ICH也与较高的出血风险相关(RR 1.014,95%可信区间1.012至1.016;p<0.001)。

放射外科的治疗后出血率、与患者的相关性和研究特征

手术通常被视为一线治疗。根据长期接受的阈值,有两次或两次以上出血史、神经功能缺损或癫痫失控的患者可考虑进行手术干预。软脑膜和室管膜的投影应该是决定积极治疗政策的决定因素之一。研究结果表明,与其他治疗方法相比,手术后大叶CCMs继发出血的风险最低(p<0.001)。此外,上述结果表明,肺叶CMs是出血的保护因素。然而,值得注意的是,包括幕上病例在内的手术系列主要治疗癫痫。因此,在术后出血减少方面可能存在结果偏差。手术通常被视为一线治疗,有两次或两次以上出血史、神经功能缺损或癫痫失控的患者可考虑进行手术干预。软脑膜和室管膜的投影应该是决定积极治疗政策的决定因素之一。复发性出血的5年风险通常高于首次出血。有趣的是,与男性患者相比,女性患者每年复发性出血的风险更高(p=0.01)。然而,在年度再出血风险方面,脑干CCMs患者与不同部位的CCMs患者在统计学上无显著差异(p=0.17)。治疗方式中不同风险因素的可能混合可能是出血率较高的原因。

手术切除CCM可以有效地预防出血,且发病率和死亡率可以接受,但保守治疗和放射外科治疗是一种合理的治疗选择。脑干和深部CCM主要与较高的出血率有关。

Bubenikova ASkalicky PBenes Jr V, et al Overview of cerebral cavernous malformations: comparison of treatment approaches

 
 

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    2022-03-15 wushaoling
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    2022-03-15 cooco

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