脑动静脉畸形大学学习教案.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,脑动静脉畸形(jxng)大学,第一页，共43页。,Incidence,0.52%,at autopsy,Slight male preponderance(1.09 to 1.94),Congenital lesions(although rarely familial)第1页/共42页,第二页，共43页。,Embryology,First half of third week of gestation,epiblastic cells migrate to form mesoderm,mesodermal cells differentiate to arterial and venous vessels on the surface of the embryonic nervous system,第2页/共42页,第三页，共43页。,Embryology,First half of third week of gestation,epiblastic cells migrate to form mesoderm,mesodermal cells differentaite to arterial and venous vessels on the surface of the embryonic nervous system,Seventh gestational week,vessels sprout branches&penetrate developing brain,reach the gray-white interface,either loop back to pial surface or traverse entire neural tube,thus epicerebral&transcerebral circn,eventually connect arterial and venous systems by around the twelfth week,第3页/共42页,第四页，共43页。,Pathology&Pathophysiology,absence of normal capillary system,第4页/共42页,第五页，共43页。,Pathology&Pathophysiology,absence of normal capillary system,usual function displaced,第5页/共42页,第六页，共43页。,Pathology&Pathophysiology,absence of normal capillary system,usual function displaced,asymptomatic at birth,第6页/共42页,第七页，共43页。,Pathology&Pathophysiology,absence of normal capillary system,usual function displaced,asymptomatic at birth,vessels change with time,may develop aneurysms,第7页/共42页,第八页，共43页。,parenchymal changes within and around the lesion,Pathology&Pathophysiology,absence of normal capillary system,usual function displaced,asymptomatic at birth,vessels change with time,may develop aneurysms,第8页/共42页,第九页，共43页。,parenchymal changes within and around the lesion,site frequency is proportional to brain volume,Pathology&Pathophysiology,absence of normal capillary system,usual function displaced,asymptomatic at birth,vessels change with time,may develop aneurysms,第9页/共42页,第十页，共43页。,Clinical presentation,95%,have symptoms by age of 70 years,第10页/共42页,第十一页，共43页。,Clinical presentation,95%,have symptoms by age of 70 years,peak presentation second to fourth decade,第11页/共42页,第十二页，共43页。,Clinical presentation,95%,have symptoms by age of 70 years,peak presentation second to fourth decade,high output failure,neonate,vein of Galen,hydrocephalus,first decade,headache,hemorrhage,seizures,2nd&3rd,第12页/共42页,第十三页，共43页。,Clinical presentation,factors contributing to symptoms,vessel walls,flow and pressures,第13页/共42页,第十四页，共43页。,Clinical presentation,factors contributing to symptoms,vessel walls,flow and pressures,enlargement and encroachment,第14页/共42页,第十五页，共43页。,Clinical presentation,factors contributing to symptoms,vessel walls,flow and pressures,enlargement and encroachment,dural sinuses,第15页/共42页,第十六页，共43页。,Clinical presentation,factors contributing to symptoms,vessel walls,flow and pressures,enlargement and encroachment,dural sinuses,ischaemia,第16页/共42页,第十七页，共43页。,Clinical presentation,factors contributing to symptoms,vessel walls,flow and pressures,enlargement and encroachment,dural sinuses,ischaemia,cardiac output,第17页/共42页,第十八页，共43页。,Clinical presentation,第18页/共42页,第十九页，共43页。,Hemorrhage,AVM,rupture not a function of size,Aneurysm,rupture related to aneurysm size,第19页/共42页,第二十页，共43页。,Hemorrhage,AVM,rupture not a function of size,no marked increase with exercise,pregnancy,trauma,Aneurysm,rupture related to aneurysm size,increase with trauma exercise,end pregnancy,第20页/共42页,第二十一页，共43页。,Hemorrhage,AVM,rupture not a function of size,no marked increase with exercise,pregnancy,trauma,arteriovenous,therefore less severe,Aneurysm,rupture related to aneurysm size,increase with trauma exercise,end pregnancy,arterial,therefore more severe,第21页/共42页,第二十二页，共43页。,Hemorrhage,AVM,rupture not a function of size,no marked increase with exercise,pregnancy,trauma,arteriovenous,therefore less severe,mortality 6 to 13.6%,Aneurysm,rupture related to aneurysm size,increase with trauma exercise,end pregnancy,arterial,therefore more severe,mortality 30-50%,第22页/共42页,第二十三页，共43页。,Hemorrhage,AVM,rupture not a function of size,no marked increase with exercise,pregnancy,trauma,arteriovenous,therefore less severe,mortality 6 to 13.6%,lower rebleed mortality rate(1%),Aneurysm,rupture related to aneurysm size,increase with trauma exercise,end pregnancy,arterial,therefore more severe,mortality 30-50%,higher rebleed mortality rate(13%),第23页/共42页,第二十四页，共43页。,Hemorrhage,AVM,rupture not a function of size,no marked increase with exercise,pregnancy,trauma,arteriovenous,therefore less severe,mortality 6 to 13.6%,lower rebleed mortality rate(1%),vasospasm rare,Aneurysm,rupture related to aneurysm size,increase with trauma exercise,end pregnancy,arterial,therefore more severe,mortality 30-50%,higher rebleed mortality rate(13%),vasospasm common,第24页/共42页,第二十五页，共43页。,Hemorrhage-AVM,Nonetheless,risk of major,incapacitating,or fatal hemorrhage in untreated lesion is 40 to 50%,第25页/共42页,第二十六页，共43页。,Hemorrhage-AVM,Nonetheless,risk of major,incapacitating,or fatal hemorrhage in untreated lesion is 40 to 50%,Yearly risk of initial hemorrhage 3%,Rebleed in first subsequent year 6-18%,reducing to 3%again thereafter,Pediatric prognosis worse than adult,第26页/共42页,第二十七页，共43页。,Spetzler&Martin Grading System,Criteria,Score,Size of Nidus,Small(6cm),3,Eloquence of Adjacent Brain,No,0,Yes,1,Deep Vascular Component,No,0,Yes,1,第27页/共42页,第二十八页，共43页。,Treatment Options,Surgical Resection,第28页/共42页,第二十九页，共43页。,Treatment Options,Surgical Resection,Endovascular Embolisation,第29页/共42页,第三十页，共43页。,Treatment Options,Surgical Resection,Endovascular Embolisation,Stereotatic Radiosurgery,第30页/共42页,第三十一页，共43页。,Treatment Options,Surgical Resection,Endovascular Embolisation,Stereotatic Radiosurgery,Multimodal Therapy,第31页/共42页,第三十二页，共43页。,Treatment Options,Surgical Resection,Endovascular Embolisation,Stereotatic Radiosurgery,Multimodal Therapy,Conservative Management,第32页/共42页,第三十三页，共43页。,Normal Perfusion Pressure Breakthrough Theory,R.F.Spetzler et al,第33页/共42页,第三十四页，共43页。,Normal perfusion pressure breakthrough theory,Loss of autoregulation and carbon dioxide reactivity in presence of large arteriovenous malformation.,第34页/共42页,第三十五页，共43页。,Normal perfusion pressure breakthrough theory,Loss of autoregulation and carbon dioxide reactivity in presence of large arteriovenous malformation.,Normal hemispheric vessels are chronically maximally dilated to attempt to divert flow from the AVM,第35页/共42页,第三十六页，共43页。,Normal perfusion pressure breakthrough theory,Loss of autoregulation and carbon dioxide reactivity in presence of large arteriovenous malformation.,Normal hemispheric vessels are chronically maximally dilated to attempt to divert flow from the AVM,Obliteration of the AVM diverts all flow to these maximally dilated vessels which have lost their normal control mechanisms,第36页/共42页,第三十七页，共43页。,Normal perfusion pressure breakthrough theory,Loss of autoregulation and carbon dioxide reactivity in presence of large arteriovenous malformation.,Normal hemispheric vessels are chronically maximally dilated to attempt to divert flow from the AVM,Obliteration of the AVM diverts all flow to these maximally dilated vessels which have lost their normal control mechanisms,Results in loss of protection of the capillary bed,with edema and hemorrhage,第37页/共42页,第三十八页，共43页。,Arterial inflow,Mathematical Models,第38页/共42页,第三十九页，共43页。,Arterial inflow,Nidus,Mathematical Models,第39页/共42页,第四十页，共43页。,Arterial inflow,Nidus,Venous Outflow,Mathematical Models,第40页/共42页,第四十一页，共43页。,Anaesthesia Technique,第41页/共42页,第四十二页，共43页。,内容(nirng)总结,脑动静脉畸形(jxng)大学。hydrocephalus,first decade。Size of Nidus。Deep Vascular Component。R.F.Spetzler et al。Anaesthesia Technique。第41页/共42页,第四十三页，共43页。,