脳動静脈奇形に対する集学的治療における定位放射線治療の役割(<特集>脳脊髄動静脈奇形の診断・治療の進歩)  [in Japanese] Role of Stereotactic Radiosurgery in a Multidisciplinary Therapeutic Approach for Arteriovenous Malformations(<SPECIAL ISSUE>Recent Progress in the Diagnosis and Treatment of Cerebral and Spinal Vascular Malformation)  [in Japanese]

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Abstract

脳動静脈奇形に対する治療法の最大の目的は出血の阻止にある.現在,摘出術,血管内治療,定位放射線治療が選択肢としてあり,その中でも定位放射線治療の役割について考察をし,最近の知見について述べる.当院で定位放射線治療を行った脳動静脈奇形714例を基に検討を行ったところ,閉塞に有意に関与する因子は,nidusの大きさ,照射線量,出血の既往であった.顕微鏡下摘出術では出血源の速やかな除去が可能だが,eloquent areaや脳深部では侵襲性が危惧される.血管内塞栓術は摘出術よりは低侵襲であるが,revascularizationがあり,単独では根治性が低い.しかし,摘出術や血管内治療後にはnidusの著しい縮小が見込め,これらでの治療が躊躇された部分への補助療法として定位放射線治療は最適であるが,治療後数〜十数年が経過した後も合併症を起こす危険性がある.以上より,今後,治療が困難な脳動静脈奇形では,定位放射線治療の後に摘出術を行うことで,顕微鏡手術に伴う"immediate and single phase risks"を軽減し,定位放射線治療後の慢性期合併症に伴う"long-lasting unclear risks"を排除できる,安全で効果的な治療戦略の構築が可能となりえる.

OBJECTIVE: The main goal of the treatment of cerebral arteriovenous malformations (AVM) is to eliminate the risk of hemorrhage. At present, microsurgical resection (MSR), endovascular embolization (EVT), and stereotactic radiosurgery (STR) are selected as the therapeutic options. In this study, the role of STR in a multidisciplinary strategy for AVM is discussed. MATERIALS: The data in this study are all based on the experience of STR with 714 AVMs in our hospital (78 were treated after MSR, 100 after EVT). RESULTS: The associated factors for nidus obliteration were nidus volume, delivered radiation dose, and past history of hemorrhage from AVM. The major benefit of MSR is the immediate elimination of hemorrhagic risks, but the procedure can be invasive in the eloquent area or the deep cerebral regions. EVT is less invasive than MSR, but revascularization of the AVM can take place. However, after MSR or EVT, a marked shrinkage of nidus volume is expected, and STR is successfully applicable for the residual AVM. It is very difficult to selectively resect the nidus component in the non-eloquent area without affecting the nidus in the eloquent area during MSR. On the other hand, the AVM becomes much less vascularized a few years after STR, and safe MSR is feasible in most cases. CONCLUSIONS: For AVM with large nidus involving the eloquent area or the deep cerebral region, the strategy using STR for the surgically intractable regions followed by MSR a few years later may be effective and simultaneously can eliminate the uncertain risks of radiation-induced complications, such as chronic encapsulated hematoma, growing cyst formation, and bleeding from obliterated nidus, taking place even years after AVM obliteration by STR.

Journal

  • Japanese Journal of Neurosurgery

    Japanese Journal of Neurosurgery 20(1), 37-41, 2011

    The Japanese Congress of Neurological Surgeons

References:  15

Codes

  • NII Article ID (NAID)
    110008007219
  • NII NACSIS-CAT ID (NCID)
    AN10380506
  • Text Lang
    JPN
  • Article Type
    REV
  • ISSN
    0917-950X
  • Data Source
    CJP  NII-ELS  J-STAGE 
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