Neurological Surgery 脳神経外科41巻5号

2013年05月発行

連載 脳神経血管内治療医に必要な知識

（9）脳・脊髄AVM塞栓術

著者： 泉孝嗣¹ 宮地茂¹

所属機関： ¹名古屋大学医学部脳神経外科

ページ範囲：P.451 - P.460

Ⅰ．はじめに

　脳動静脈奇形（arteriovenous malformation：AVM）の塞栓術の歴史は長く，最も古くから行われてきている脳血管内治療手技の1つである．AVMの治療は塞栓術以外にも外科的摘出術と定位放射線治療（stereotactic radiosurgery）とがあり，いずれか単独ないしはcombinationで治療が行われている．塞栓術は単独では根治を得ることが難しく，外科的摘出の前処置や定位放射線治療との組み合わせで用いられることが多いが，小さな病変に対しては単独で完全閉塞が得られる機会も少なくない．また，近年では塞栓物質や医療器材の発展に伴い，塞栓術単独でも高い完全閉塞率が報告されているが，本邦では保険上の制約や使用できるデバイスの制限があるため，残念ながら塞栓術の役割は大きくは変化していない．いずれにせよ，症例ごとに塞栓術の位置づけを明確に設定し，その目的に応じた塞栓計画に基づいて治療を実施する必要がある．本稿では脳・脊髄AVMの多角的治療の1つとしての塞栓術について述べる．

参考文献

1) Brown RD Jr, Wiebers DO, Forbes G, O'Fallon WM, Piepgras DG, Marsh WR, Maciunas RJ：The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68：352-357, 1988

2) Chaloupka JC, Huddle DC, Alderman J, Fink S, Hammond R, Vinters HV：A reexamination of the angiotoxicity of superselective injection of DMSO in the swine rete embolization model. AJNR Am J Neuroradiol 20：401-410, 1999

3) Crawford PM, West CR, Chadwick DW, Shaw MD：Arteriovenous malformations of the brain：natural history in unoperated patients. J Neurol Neurosurg Psychiatry 49：1-10, 1986

4) Friedman WA, Bova FJ, Bollampally S, Bradshaw P：Analysis of factors predictive of success or complications in arteriovenous malformation radiosurgery. Neurosurgery 52：296-307；discussion 307-308, 2003

5) Fults D, Kelly DL Jr：Natural history of arteriovenous malformations of the brain：a clinical study. Neurosurgery 15：658-662, 1984

6) Gobin YP, Laurent A, Merienne L, Schlienger M, Aymard A, Houdart E, Casasco A, Lefkopoulos D, George B, Merland JJ：Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 85：19-28, 1996

7) Graf CJ, Perret GE, Torner JC：Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58：331-337, 1983

8) Gross BA, Du R：Natural history of cerebral arteriovenous malformations：a meta-analysis. J Neurosurg 118：437-443, 2013

9) Hall WA, Oldfield EH, Doppman JL：Recanalization of spinal arteriovenous malformations following embolization. J Neurosurg 70：714-720, 1989

10) Hamilton MG, Spetzler RF：The prospective application of a grading system for arteriovenous malformations. Neurosurgery 34：2-6；discussion 6-7, 1994

11) Han PP, Ponce FA, Spetzler RF：Intention-to-treat analysis of Spetzler-Martin grades IV and V arteriovenous malformations：natural history and treatment paradigm. J Neurosurg 98：3-7, 2003

12) Hartmann A, Pile-Spellman J, Stapf C, Sciacca RR, Faulstich A, Mohr JP, Schumacher HC, Mast H：Risk of endovascular treatment of brain arteriovenous malformations. Stroke 33：1816-1820, 2002

13) Kano H, Kondziolka D, Flickinger JC, Park KJ, Iyer A, Yang HC, Liu X, Monaco EA 3rd, Niranjan A, Lunsford LD：Stereotactic radiosurgery for arteriovenous malformations after embolization：a case-control study. J Neurosurg 117：265-275, 2012

14) 菊池晴彦（総監修）：脳神経血管内治療のすべて―最新の症例から学ぶ―．にゅーろん社，東京，2007, pp230-231

15) Lunsford LD, Kondziolka D, Flickinger JC, Bissonette DJ, Jungreis CA, Maitz AH, Horton JA, Coffey RJ：Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75：512-524, 1991

16) Maruyama K, Kawahara N, Shin M, Tago M, Kishimoto J, Kurita H, Kawamoto S, Morita A, Kirino T：The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations. N Engl J Med 352：146-153, 2005

17) Meisel HJ, Mansmann U, Alvarez H, Rodesch G, Brock M, Lasjaunias P：Cerebral arteriovenous malformations and associated aneurysms：analysis of 305 cases from a series of 662 patients. Neurosurgery 46：793-800；discussion 800-802, 2000

18) Miyachi S, Negoro M, Okamoto R, Otsuka G, Suzuki O, Yoshida J：Embolization of arteriovenous malformations prior to radiosurgery. Interv Neuroradiol 6 (Suppl) 1：131-137, 2000

19) 宮地　茂，根来　真，岡本　剛，大塚吾郎，鈴木　宰，佐原佳之，𠮷田　純：脳動静脈奇形の治療方針―塞栓術の適応と現状について―．脳卒中の外科6：391-396, 2001

20) 宮地　茂，根来　真，鈴木　宰，服部光爾，小林　望，小島隆生，𠮷田　純：脳動静脈奇形の血管内治療：適応，治療方針，臨床結果．脳外誌11：660-667, 2002

21) 宮地　茂，岡本　剛，小林　望，小島隆生，服部健一，中井完治，鈴木　宰，佐原佳之，服部光爾，根来　真，𠮷田　純：動静脈奇形の治療における血管内治療の意義―付随動脈瘤の処置について―．脳卒中の外科33：357-362, 2005

22) 宮地　茂：Onyxを用いた脳動静脈奇形塞栓術．血栓と循環20：223-228, 2012

23) 宮坂和男（編著）：脳・脊髄血管造影マニュアル．南江堂，東京，1997, p153

24) Morgan MK, Zurin AA, Harrington T, Little N：Changing role for preoperative embolisation in the management of arteriovenous malformations of the brain. J Clin Neurosci 7：527-530, 2000

25) Murayama Y, Vinuela F, Ulhoa A, Akiba Y, Duckwiler GR, Gobin YP, Vinters HV, Greff RJ：Nonadhesive liquid embolic agent for cerebral arteriovenous malformations：preliminary histopathological studies in swine rete mirabile. Neurosurgery 43：1164-1175, 1998

26) Natarajan SK, Born D, Ghodke B, Britz GW, Sekhar LN：Histopathological changes in brain arteriovenous malformations after embolization using Onyx or N-butyl cyanoacrylate. Laboratory investigation. J Neurosurg 111：105-113, 2009

27) Niimi Y, Berenstein A, Setton A, Neophytides A：Embolization of spinal dural arteriovenous fistulae：results and follow-up. Neurosurgery 40：675-682；discussion 682, 1997

28) Ogilvy CS, Stieg PE, Awad I, Brown RD Jr, Kondziolka D, Rosenwasser R, Young WL, Hademenos G：AHA Scientific Statement：Recommendations for the management of intracranial arteriovenous malformations：a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 32：1458-1471, 2001

29) Pollock BE, Flickinger JC, Lunsford LD, Maitz A, Kondziolka D：Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery 42：1239-1244；discussion 1244, 1998

30) Song JK, Vinuela F, Gobin YP, Duckwiler GR, Murayama Y, Kureshi I, Frazee JG, Martin NA：Surgical and endovascular treatment of spinal dural arteriovenous fistulas：long-term disability assessment and prognostic factors. J Neurosurg 94：199-204, 2001

31) van Beijnum J, van der Worp HB, Buis DR, Al-Shahi Salman R, Kappelle LJ, Rinkel GJ, van der Sprenkel JW, Vandertop WP, Algra A, Klijn CJ：Treatment of brain arteriovenous malformations：a systematic review and meta-analysis. JAMA 306：2011-2019, 2011

32) Van Dijk JM, TerBrugge KG, Willinsky RA, Farb RI, Wallace MC：Multidisciplinary management of spinal dural arteriovenous fistulas：clinical presentation and long-term follow-up in 49 patients. Stroke 33：1578-1583, 2002

33) Velat GJ, Reavey-Cantwell JF, Sistrom C, Smullen D, Fautheree GL, Whiting J, Lewis SB, Mericle RA, Firment CS, Hoh BL：Comparison of N-butyl cyanoacrylate and onyx for the embolization of intracranial arteriovenous malformations：analysis of fluoroscopy and procedure times. Neurosurgery 63：ONS73-78；discussion ONS78-80, 2008

34) Westphal M, Koch C：Management of spinal dural arteriovenous fistulae using an interdisciplinary neuroradiological/neurosurgical approach：experience with 47 cases. Neurosurgery 45：451-457；discussion 457, 1999

35) Wikholm G, Lundqvist C, Svendsen P：The Göteborg cohort of embolized cerebral arteriovenous malformations：a 6-year follow-up. Neurosurgery 49：799-805；discussion 805-806, 2001

36) Wilkins RH：Natural history of intracranial vascular malformations：a review. Neurosurgery 16：421-430, 1985

37) Yamamoto Y, Coffey RJ, Nichols DA, Shaw EG：Interim report on the radiosurgical treatment of cerebral arteriovenous malformations. The influence of size, dose, time, and technical factors on obliteration rate. J Neurosurg 83：832-837, 1995

38) Yashar P, Amar AP, Giannotta SL, Yu C, Pagnini PG, Liu CY, Apuzzo ML：Cerebral arteriovenous malformations：issues of the interplay between stereotactic radiosurgery and endovascular surgical therapy. World Neurosurg 75：638-647, 2011