摘要： 目的 分析并总结儿童脑动静脉畸形最佳治疗方式，以及相关疗效及预后。方法 回顾分析天津市环湖医院神经外科2011年10月至2022年9月收治的47例儿童（< 18岁）脑动静脉畸形患者的临床资料，通过Spetzler-Martin分级和畸形血管团致密度分型评价显微外科手术、伽马刀放射治疗或多模式治疗方式的风险，了解畸形血管团供血动脉和引流静脉结构、走行；以手术全切除率、患儿预后和影像学随访结果作为疗效评价指标。结果 共计74.47%（35/47）患儿接受显微外科手术治疗，脑出血< 1周手术者28.57%（10/35）、> 1周者71.43%（25/35）；12.77%（6/47）密切随访；6.38%（3/47）伽马刀放射治疗；6.38%（3/47）采取多模式治疗［显微外科手术+栓塞术和（或）伽马刀放射治疗］。Spetzler-Martin分级Ⅰ~Ⅲ级（低级别）患儿占80.85%（38/47），76.32%（29/38）行显微外科手术，多模式治疗占2.63%（1/38）和伽马刀放射治疗占5.26%（2/38），15.79%（6/38）密切随访；手术全切除Ⅰ级9/9例、Ⅱ级13/14例、Ⅲ级6/9例；术后共随访5年，21.05%（8/38）预后不良、2.63%（1/38）复发。Spetzler-Martin分级Ⅳ~Ⅴ级（高级别）9例，显微外科手术6例、多模式治疗2例、伽马刀放射治疗1例；手术全切除Ⅳ级4/8例、Ⅴ级1/1例，有5例预后不良，无复发病例。畸形血管团致密度分型致密型患儿手术全切除17/17例、弥散型66.67%（16/24）；术后预后不良者致密型3/18例、弥散型34.48%（10/29）。结论 目前针对儿童脑动静脉畸形的治疗仍提倡积极的显微外科手术治疗，以脑出血时间超过1周手术为宜；术前充分评价手术风险、畸形血管团致密程度，有利于选择最佳治疗方案，提高病灶全切除率，改善患儿预后。

关键词: 颅内动静脉畸形, 显微外科手术, 栓塞, 放射外科手术, 脑血管造影术, 儿童

Abstract: Objective To investigate the optimal clinical therapy effects and prognostic factors of cerebral arteriovenous malformation (CAVM) in children following different treatment methods. Methods The clinical data of 47 children (< 18 years old) with CAVM who were admitted to Tianjin Huanhu Hospital from October 2011 to September 2022 were collected, and the multimodality treatment and prognostic factors of different grades were analyzed. Spetzler-Martin grading system and vascular nest dispersion classification were used to evaluate the risk and angiogenesis of CAVM, different treatment modalities such as microsurgery, gamma knife radiosurgery, and multi-mode therapy were used to evaluate the total resection rate, prognosis, and imaging follow -up results. Results 1) Treatment plan:among the total 47 children in this group, 35 (74.47%) received simple microsurgery, of which 10 (28.57%) suffered surgery within one week of hemorrhage, and 25 (71.43%) suffered surgery over one week; 6 (12.77%) received conservative treatment; 3 (6.38%) received gamma knife radiosurgery; 3 (6.38%) received multimodal therapy (microsurgery + interventional embolism/gamma knife radiosurgery). 2) Spetzler-Martin grading and prognosis:among the 38 patients (80.85%) of Spetzler-Martin grade Ⅰ-Ⅲ, 29 (76.32%) underwent microsurgery, one (2.63%) received multimodal therapy, and 2 (5.26%) received gamma knife radiosurgery. The total surgical resection rate was 9/9 in grade Ⅰ, 13/14 in grade Ⅱ and 6/9 in grade Ⅲ. Eight patients (21.05%) had a poor prognosis during 5 years followed-up period. There was one (2.63%) recurrence on imaging follow-up. underwent microsurgery, 2 patients received multimodal therapy, and one received gamma knife radiosurgery. Total surgical resection rate was 4/8 in grade Ⅳ and 1/1 in grade Ⅴ, and prognosis was poor in 5 cases. 3) Diffusion classification and prognosis of malformed vascular mass:the total resection rate of dense type was 17/17, and that of diffuse type was 66.67% (16/24). The incidence of poor prognosis was 3/18 for dense type and 34.48% (10/29) for diffuse type. Conclusions safe and effective method for the treatment of CAVM in children. The operation was recommended to be performed at least one week after acute hemorrhage if possible. A preoperative evaluation of surgical risks and the density of abnormal vascular clusters can assist in selecting the best treatment plan, thus could increase the total resection rate of lesions and improve the prognosis.

Key words: Intracranial arteriovenous malformations, Microsurgery, Embolism, Radiosurgery, Cerebral angiography, Child