• 대한족부족관절학회지
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• 제19권1호
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• pp.23-26
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• 2015

Arteriovenous malformations (AVMs) are characterized by the presence of abnormal connections between feeding arteries and draining veins. It is generally assumed that symptomatic lesions can preferably be treated. Due to high arterial blood flow, there is a risk of bleeding with surgical excision alone, which can be massive and life threatening during the operation. According to recent advances in interventional technique, a hybrid approach using embolization of the feeding artery with subsequent immediate excision of the AVM for successful management of vascular lesions could be applied to AVMs. Herein, we describe a case of successful excision of AVM in the left soleus muscle using a hybrid approach.

• Tuberculosis and Respiratory Diseases
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• 제78권4호
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• pp.408-411
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• 2015

Pulmonary arteriovenous malformations (AVMs) are caused by abnormal vascular communications between the pulmonary arteries and pulmonary veins, which lead to the blood bypassing the normal pulmonary capillary beds. Pulmonary AVMs result in right-to-left shunts, resulting in hypoxemia, cyanosis, and dyspnea. Clinical signs and symptoms vary depending on the size, number, and flow of the AVMs. Transcatheter embolization is the treatment of choice for pulmonary AVMs. However, this method can fail if the AVM is large or has multiple complex feeding arteries. Surgical resection is necessary in those kind of cases. Here, we report the case of a patient with a 6-cm pulmonary AVM with multiple feeding arteries that was successfully treated by repeated coil embolization without surgery.

• Journal of Korean Neurosurgical Society
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• 제57권2호
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• pp.88-93
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• 2015

Objective : Elevated cellular retinoic acid binding protein-I (CRABP-I) is thought to be related to the abnormal proliferation and migration of smooth muscle cells (SMCs). Accordingly, a higher CRABP-I level could cause disorganized vessel walls by causing immature SMC phenotypes and altering extracellular matrix proteins which could result in vulnerable arterial walls with inadequate responses to hemodynamic stress. We hypothesized that elevated CRABP-I level in the cerebrospinal fluid (CSF) could be related to subarachnoid hemorrhage (SAH). Moreover, we also extended this hypothesis in patients with vascular malformation according to the presence of hemorrhage. Methods : We investigated the CSF of 26 patients : SAH, n=7; unruptured intracranial aneurysm (UIA), n=7; arteriovenous malformation (AVM), n=4; cavernous malformation (CM), n=3; control group, n=5. The optical density of CRABP-I was confirmed by Western blotting and presented as mean${\pm}$standard error of the measurement. Results : CRABP-I in SAH ($0.33{\pm}0.09$) was significantly higher than that in the UIA ($0.12{\pm}0.01$, p=0.033) or control group ($0.10{\pm}0.01$, p=0.012). Hemorrhage presenting AVM (mean 0.45, ranged 0.30-0.59) had a higher CRABP-I level than that in AVM without hemorrhage presentation (mean 0.16, ranged 0.14-0.17). The CRABP-I intensity in CM with hemorrhage was 0.21 and 0.31, and for CM without hemorrhage 0.14. Overall, the hemorrhage presenting group (n=11, $0.34{\pm}0.06$) showed a significantly higher CRABP-I intensity than that of the non-hemorrhage presenting group (n= 10, $0.13{\pm}0.01$, p=0.001). Conclusion : The results suggest that elevated CRABP-I in the CSF could be related with aneurysm rupture. Additionally, a higher CRABP-I level seems to be associated with hemorrhage development in vascular malformation.

• Journal of Korean Neurosurgical Society
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• 제29권8호
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• pp.1126-1135
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• 2000

Objectives : The goal of surgical management of cerebral arteriovenous malformation(AVM) is elimination of the lesion without development of new neurological deficits. To improve the management results of cerebral AVMs in the future, this article discusses about surgical complications of the AVM and their management. Material and Methods : During the past 18 years, 116 patients with cerebral AVMs were managed by surgery. Among these cases, 7 cases died, 7 cases developed new neurological deficits, 11 cases residual AVM and 5 cases intracerebral hematoma(ICH) after surgery. The author analyzes the causes of those complications and investigates the methods to minimized those complications based on the review of the literatures. Results : One stage removal of AVM and ICH in the poor neurological state were performed in 5 of 7 death cases. Subtotal removal of ICH followed by delayed AVM surgery after recovery is regard as one method to improve the outcome of patient with large ICH. Postoperative new neurological deficits developed owing to normal perfusion pressure breakthrough(NPPB) in 3, judgement error in 2, preoperative embolization in 1 and cortical injury in 1 case(s). Proper management of NPPB, accurate anatomical knowledge and physiological monitoring during operation, and well trained skill for embolization are regard as methods to minimize those complications. Residual AVMs after surgery were noticed in 11 cases, in which unintended 6 cases due to inaccurate dissection of peripheral margin of AVM, and intended 3 cases due to massive brain swelling during operation, 1 cases due to diffuse type and 1 case due to multiple type of AVM. Accurate dissection of peripheral margin of AVM and mild hypotension during operation may help to avoid this complication. Postoperative hemorrhage occurred in 3 cases due to rupture of the residual AVM and in 2 cases due to oozing from the AVM bed. Complete resection of AVM, complete control of bleeding points at AVM bed and mild hypotension during early postoperative period are the methods to avoid this complication. Conclusion : A precise but flexible therapeutic strategy and refined skill for endovascular, radiosurgical and microsurgical techniques are required to successful treatment of cerebral AVM. Adequate timing of AVM resection, accurate anatomical knowledge, proper management of NPPB and accurate dissection of peripheral margin of AVM are the key points for avoiding complications of the AVM surgery.

• 대한영상의학회지
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• 제84권1호
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• pp.226-239
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• 2023

목적 뇌동정맥루(arteriovenous fistula; 이하 AVF), 뇌동정맥기형(arteriovenous malformation; 이하 AVM), 경동맥해면정맥동루(carotid-cavernous sinus fistula; 이하 CCF) 등 뇌동정맥단락을 진단하는 데 있어서, T2 강조영상(T2-weighted imaging; 이하 T2WI)과 자화율 강조영상(susceptibility-weighted imaging; 이하 SWI)의 민감도를 비교하고, 단일 에코(single-echo) SWI(이하 s-SWI)와 다중 에코(multi-echo) SWI (이하 m-SWI)의 전반적인 영상 질을 비교하고자 하였다. 대상과 방법 2016년부터 2021년까지 뇌혈관조영술로 입증된 뇌동정맥단락을 조사하였다. 뇌동정맥단락에 대한 T2WI와 SWI의 민감도를 McNemar's Test를 이용하여 비교하였다. s-SWI와 m-SWI의 영상 질을 나쁨, 보통, 좋음으로 분류하고 Fisher's exact test를 이용하여 그 비율을 비교하였다. 결과 총 24명의 환자(중위 연령: 61세, 여성: 12명, 남성: 12명)가 연구에 포함되었다. 그중 4명은 s-SWI와 m-SWI 두 가지의 SWI로, 나머지 20명은 이 중 한 가지의 SWI로 검사하였다. 10명은 AVF, 11명은 AVM, 3명은 CCF로 진단되었고, 이와 같은 뇌동정맥단락에 대해, SWI는 T2WI 보다 유의하게 높은 민감도를 보였다(82.1% vs. 53.6%, p = 0.013). m-SWI는 s-SWI 보다 좋은 영상 질의 비율이 유의하게 높았다(83.3% vs. 25.0%, p = 0.009). 결론 SWI는 T2WI 보다 뇌동정맥단락을 더 민감하게 진단해 낼 수 있었으며, m-SWI는 s-SWI보다 혈관질환을 평가하는데 더 좋은 영상 질을 보였다.

• Journal of Korean Neurosurgical Society
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• 제29권6호
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• pp.815-821
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• 2000

Parasplenial arteriovenous malformations(AVMs) are rare vascular malformations which have distinct clinical and anatomical features. They are situated at the confluence of the hippocampus, isthmus of the cingulate gyrus and the gyrus occipitotemporalis medialis. These lesions are anterior to the calcarine sulcus and their apex extends towards the medial surface of the trigonum. Posterolaterally, these lesions are in close proximity to the visual cortex and optic radiation. The objectives in the surgery of parasplenial AVMs are complete resection of the lesions and preservation of vision. These objectives must be achieved with comprehensive understanding of the following anatomical features :1) the deep central location of the lesions within eloquent brain tissue ; 2) the lack of cortical representation of the AVMs that requires retraction of visual cortex ; 3) deep arterial supply ; 4) deep venous drainage ; 5) juxtaposition to the choroid plexus with which arterial supply and venous drainage are shared. A 16-year-old female student presented with intraventricular hemorrhage from a right parasplenial-subtrigonal AVM. The lesion, fed by posterior cerebral artery and drained into the vein of Galen, was successfully treated by the inter-hemispheric parietooccipital approach. To avoid visual field defect a small incision was made on precuneus anterior to the calcarine sulcus. In this report, the authors describe a surgical approach with special consideration on preservation of visual field.

• Journal of Korean Neurosurgical Society
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• 제52권6호
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• pp.534-540
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• 2012

Objective : Brainstem arteriovenous malformation (AVM) is rare and radiosurgical management is complicated by the sensitivity of the adjacent neurological structures. Complete obliteration of the nidus is not always possible. We describe over 20 years of radiosurgical procedures for brainstem AVMs, focusing on clinical outcomes and radiosurgical techniques. Methods : Between 1992 and 2011, the authors performed gamma knife radiosurgery (GKRS) in 464 cerebral AVMs. Twenty-nine of the 464 patients (6.3%) reviewed had brainstem AVMs. This series included sixteen males and thirteen females with a mean age of 30.7 years (range : 5-71 years). The symptoms that led to diagnoses were as follows : an altered mentality (5 patients, 17.3%), motor weakness (10 patients, 34.5%), cranial nerve symptoms (3 patients, 10.3%), headache (6 patients, 20.7%), dizziness (3 patients, 10.3%), and seizures (2 patients, 6.9%). Two patients had undergone a previous nidus resection, and three patients had undergone a previous embolization. Twenty-four patients underwent only GKRS. With respect to the nidus type and blood flow, the ratio of compact type to diffuse type and high flow to low flow were 17 : 12 and 16 : 13, respectively. In this series, 24 patients (82.8%) had a prior hemorrhage. The mean target volume was 1.7 $cm^3$ (range 0.1-11.3 $cm^3$). The mean maximal and marginal radiation doses were 38.5 Gy (range 28.6-43.6 Gy) and 23.4 Gy (range 18-27 Gy), and the mean isodose profile was 61.3% (range 50-70%). Results : Twenty-four patients had brainstem AVMs and were followed for more than 3 years. Obliteration of the AVMs was eventually documented in 17 patients (70.8%) over a mean follow-up period of 77.5 months (range 36-216 months). With respect to nidus type and blood flow, the obliteration rate of compact types (75%) was higher than that of diffuse types (66.7%), and the obliteration rate of low flow AVMs (76.9%) was higher than that of high flow AVMs (63.6%) (p<0.05). Two patients (6.9%) with three hemorrhagic events suffered a hemorrhage during the follow-up period. The annual bleeding rate of AVM after GKRS was 1.95% per year. No adverse radiation effects or delayed cystic formations were found. Conclusion : GKRS has an important clinical role in treatment of brainstem AVMs, which carry excessive surgical risks. Angiographic features and radiosurgical techniques using a lower maximal dose with higher isodose profiles are important for lesion obliteration and the avoidance of complications.

• Journal of Korean Neurosurgical Society
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• 제29권4호
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• pp.500-506
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• 2000

뇌동정맥기형의 치료에 있어 술 전 색전술과 미세뇌수술을 병합함으로서 얼마나 치료효과를 높일 수 있는지를 알고자 후향적조사를 시행하였다. 조사군은 수술 전 초선택적 색전술후 수술을 시행하였던 10명의 뇌동정맥기형 환자를 대상으로 하였고, 대조군은 술 전 색전술 없이 수술만으로 치료하였던 27명의 환자를 대상으로 하였으며 각각의 환자군은 Spetzler-Martin grade, 뇌동정맥기형의 크기 그리고 Glasgow Outcome Scale을 이용한 술 후 추적관찰 결과에 따라 나누어 비교하였다. 조사대상 37명의 환자중 남자가 23명, 여자가 14명이었으며 나이는 11세부터 74세(평균 36세)였다. 뇌동정맥기형의 크기는 술 전 색전술과 수술적 치료를 병합하였던 조사군에서 평균 4.45cm로 수술만 시행하였던 군의 3.83cm에 비해 크게 나타났으며, Spetzler-Martin grade도 조사군에서는 3, 4, 5등급이 80%이었으나 대조군에서는 52%로 술 전 색전술과 수술을 병합한 군에서 높은 등급의 환자가 많았다. 수술 후 일주일째 평가한 Glasgow-Outcome Scale 점수는 조사군에서는 5점인 경우가 60%로 대조군의 44%보다 높았으며, 수술 후 6개월만에 평가한 점수도 조사군에서 5점인 경우가 80%이었고 대조군은 63%로 술 전 색전술과 수술을 병합하였던 환자에서 더 좋은 예후를 보였다. 결론적으로 수술 전 N-butyl cyanoacrylate를 이용한 초선택적 색전술을 시행한 후 수술 적으로 뇌동정맥기형을 제거함으로서 비교적 등급이 높은 환자에서 치료가 용이하였으며 이전의 수술적 치료만 하였던 경우에 비해 더 좋은 예후를 보임을 알 수 있었다.

• 대한영상의학회지
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• 제82권4호
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• pp.1018-1023
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• 2021

사행 폐정맥(meandering pulmonary vein)은 드물게 보이는 폐 혈관 이상으로, 사행성 주행을 보이는 폐정맥이 좌심방으로 배출되는 것을 특징으로 하는 질환이다. 우리는 조영증강흉부 전산화단층촬영 및 폐 혈관 조영술 후 우측 사행 폐정맥으로 진단된 55세 여성 환자를 보고하고자 한다. 조영증강 흉부 전산화단층촬영상 우상폐정맥으로 배출되는 구불구불한 사행성 경로를 보이는 혈관구조물이 우상엽에 있었고, 폐 동정맥 기형이 의심되었다. 진단 및 치료를 위해 폐혈관 조영술이 시행되었고, 폐혈관 조영술에서 먹이 동맥(feeding artery)은 보이지 않았고, 환자는 우측 사행 폐정맥으로 진단되었다. 조영증강 흉부 전산화단층촬영에서 사행 폐정맥과 다른 혈관 기형의 감별이 어려운 경우, 폐혈관 조영술 소견이 진단에 도움이 되며, 추가로 시행할 수 있는 진단도구가 되겠다. 사행 폐정맥의 혈관 조영 소견을 인식함으로써 불필요한 치료가 시행되는 것을 예방할 수 있다.

• Journal of Korean Neurosurgical Society
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• 제46권4호
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• pp.378-384
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• 2009

Objective : In order to establish the role of Gamma Knife radiosurgery (GKS) in large intracranial arteriovenous malformations (AVMs), we analyzed clinical characteristics, radiological features, and radiosurgical outcomes. Methods : Between March 1992 and March 2005, 28 of 33 patients with large AVMs (> $10\;cm^3$ in nidus-volume) who were treated with GKS underwent single session radiosurgery (RS), and the other 5 patients underwent staged volumetric RS. Retrospectively collected data were available in 23 cases. We analyzed treatment outcomes in each subdivided groups and according to the AVM sizes. We compared the estimated volume, defined as primarily estimated nidus volume using MR images, with real target volume after excluding draining veins and feeding arteries embedded into the nidus. Results : Regarding those patients who underwent single session RS, 44.4% (8/18) had complete obliteration; regarding staged volumetric RS, the obliteration rate was 40% (2/5). The complete obliteration rate was 60% (6/10) in the smaller nidus group ($10-15\;cm^3$ size), and 25% (2/8) in the larger nidus group (over $15\;cm^3$ size). One case of cerebral edema and two cases (8.7%) of hemorrhage were seen during the latent period. The mean real target volume for 18 single sessions of RS was $17.1\;cm^3$ ($10.1-38.4\;cm^3$), in contrast with the mean estimated volume of $20.9\;cm^3$ ($12.0-45.0\;cm^3$). Conclusion : The radiosurgical treatment outcomes of large AVMs are generally poor. However, we presume that the recent development in planning software and imaging devices aid more accurate measurement of the nidus volume, therefore improving the treatment outcome.