颅内病变，肿瘤？炎症？avm？您的看法
患者，男，50岁，头痛幻嗅记忆力下降十月加重伴恶心呕吐10天住院。
患者10年前“腰椎结核”行系统抗痨治疗，复查3年无异常。
06年10月“蛛网膜下腔出血”当地医院未予特殊处理
查体：神清，体温及生命体征正常，记忆力，计算力下降，眼底无水肿，四肢肌力、肌张力正常。
入院后查3大常规、肝肾功能、血沉及胸片腰椎照片均正常
PPD+++csf -r 潘氏实验＋细胞总数 26 白细胞 6 csf－生化 pro4.81g/l glu5.89mmol/l cl 115.6mmol/l
下面依次传送图片，请大家看看是什么？
术前科内有会诊，家属有请天坛教授看过，术后有病检及mri复查
标签： 耳源性颅内并发症, 颅内动脉瘤, 颅内血肿
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这篇文章发布于 2010年01月31日，星期天，10:22 下午，归类于 未分类。 您可以跟踪这篇文章的评论通过 RSS 2.0 feed。
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切下的标本，外周蔓状血管，病变大部鱼肉状，少部黄染，质地稍韧
手术顺利，出血约400ml，病变供血来源mca，pca。图为切除后的情况。病理明天公布。
病史相对较长.10月.看起来病情发展相对较慢.MRI上有血管流空,DSA上可见明显成团块壮阴影.CT片上右侧脑室继发出血.片子上占位效应及水肿均不明显.目前来看支持”颅内血管畸形”.是肿瘤吗?冠状为上病找主要位于有侧颞叶.且位置较深靠近中线.诺为相对恶性的肿瘤如胶质瘤3–4级,则颅高压症状及全身症状应更明显.且不管怎样占位应更明显.诺为低度恶性的肿瘤如胶质瘤1–2级肿瘤中的坏死能这么快吗?如果这么快的话说明肿瘤生长很快这样病情的进展应更快.因CSF有阳性发现,结合有结核病史我想还是应该考虑.但中枢性的结核瘤鲜有坏死.
哈哈镜了；可；
哈哈镜了；可；改变，基本可。
胶质瘤的可能性较大，病程相对较长，应该是1-2级的。
结核可能性大
肉芽肿病变可能最大
胶质瘤吗
谢谢，老师的资料，受教了，
猜一个病，结核肉芽肿？
脉络丛乳头状瘤
moyamoya
考虑为AVM合并脑室内出血
胶质瘤吗 ,结核肉芽肿？ 不像
动静脉畸形的可能性大
谢谢各位的关注，本院病理结果考虑：胶质瘤2级并avm。
然有下述问题须考虑：
1；畸形血管术中仅见分布于表面，是否符合avm？
2：侧脑室及4脑室病变如何定性？下一步如何治疗？适合伽玛刀治疗吗？
欢迎各位继续关注，谈谈您的看法
术后mri
再来一张
出院10天后
出院10天后mri
1. AVM 应有三个要素：1供血动脉2粗大的回流静脉3畸形血管团，为先天性疾病，一般四十岁以前发病，本病例的DSA不符合，MRI应该有很多流空，不应有片状的强化。病理上AVM的血管壁有其独特的特征
2多发的胶质瘤，手术已切除主要的病灶，是否放化疗要问贵院的病理科医生，“胶质瘤“显然是一个很粗略的诊断，但血供很丰富，我想放射治疗应该是有效的。
maozhen2000, Thanks for providing such a wonderful case.
I just reviewed some related publications and obtainted one of the literature entitled “A glioma with an arteriovenous malformation: an association or a different entity?”
I’ll post the abstract and the figues here, and I hope it will help you with the selection of treatment strategy.
Also, the accurate pathology and operation detail of this case (provided by you) is recommended. Thanks!
Abstract and fig 1
Acta Neurochir (Wien). 2004 Jan;146(1):83-6; discussion 86. Epub 2003 Dec 5.
A glioma with an arteriovenous malformation: an association or a different entity?Ziyal IM, Ece K, Bilginer B, Tezel GG, Ozcan OE.
Department of Neurosurgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey. ibrahimziyal@yahoo.com
A 58-year-old male was admitted with headache to our neurosurgery clinic. His neurological examination revealed slight left hemiparesis. The radiological evaluation with contrast administred magnetic resonance imaging (MRI) scan demonstrated a right temporo-parietal ring enhancing mass lesion surrounded by edema which was resembling a typical glioma (Fig. 1). The patient was operated on via a temporo-parietal craniotomy and an arteriovenous malformation surrounded by abnormal glial tissue was observed during the exposure. A nidus supplied by several branches arising from the middle cerebral artery (MCA) was obvious. The venous drainage of the malformation was to the superficial venous system. The observed arterial feeders and the draining vein were coagulated and the nidus was macroscopically totally excised. The frozen examination from surrounding glial tissue revealed a high grade glioma. The tumor was also macroscopically totally excised. Postoperatively, the cerebral angiogram demonstrated a right temporal arteriovenous malformation with a centrally excised nidus. The remaining major feeders involved the angular gyrus and the posterior temporal arteries. The venous drainage was to the straight and sigmoid sinuses (Fig. 2). The final histopathological examination of the specimen revealed an arteriovenous malformation surrounded by a high grade glioma (Fig. 3). The patient refused a second operation for total removal of the AVM. Postoperatively, he is doing well with improvement of his left hemiparesis.
Figue 2
Figue 3
完全同意同行timbo对DSA的分析，不过对于MRI图像的分析不敢完全认同。楼主给的平扫真的太少了，只要一张T1WI平扫，而给的图像中可见右侧颞叶可见不均匀低信号区内有更低信号，似可见到流空信号影，但没有看到明显的亚急性出血表现。增强后强化明显而且范围蛮大的，中间有不强化区域，与平扫更低信号区相一致。所给CT是脑室内出血，而MRI亦未见脑实质出血的表现，说明应该是破入脑室的。考虑还是AVM并脑室内出血。
通过阅片及术中图片所见，我不太主张用两个病来解释，肿瘤主要由大脑中，大脑前动脉供血，我个人认为可考虑为富血管肿瘤。至于术后残余病变的治疗我建议采用放射治疗。病人情况允许，可考虑再次手术。
1 Acta Neurochir (Wien). 1995;133(3-4):169-73.
Cavernous angioma associated with oligo-astrocytoma-like proliferation. Report of two cases and review of the literature with a reappraisal of the term “angioglioma”.Palma L, Mastronardi L, Celli P, d’Addetta R.
Chair of Neurosurgery, University of Siena, Italy.
Reporting two cases of cavernous angioma closely associated with oligo-astrocytoma we were stimulated to revise the proper use of the term “angioglioma”, introduced by Councilman 80 years ago7. In the past this term was often used in a merely descriptive sense i.e. either to give a name to an exceptional coincidence of AVM and glioma or simply to describe a hypervascularized glioma. Today, according to the majority of authors, such a use of this term has to be rejected as inappropriate. Occasionally however the term angioglioma has been used to designate a true mixed composite neoplasm developed after the transformation of both glial and angiogenic elements determined by simultaneously or consecutively acting (even possibly intermingled) oncogenic factors. Among reported cases claimed to be examples of “true” angioglioma, the association cavernomaoligodendroglioma/astrocytoma seems the most intriguing besides being also the most frequent one. Opinions about this topic however did continue to be unequivocal. While some authors regarded the oligodendroglial proliferation associated with AVM as merely reactive or malformative, others considered it as truly neoplastic putting forward the hypothesis of a common viral or genetic aetiology for both AVM and glioma.
2 J Surg Oncol. 1996 May;62(1):15-21.
Combined angioma and glioma (angioglioma).Kasantikul V, Shuangshoti S, Panichabhongse V, Netsky MG.
Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
Ten patients in whom tissue proliferation akin to angioglioma occurred within the brain are described; seven of the lesions were supratentorial and three infratentorial. Only 31 accepted instances of such neoplasms have been found in the literature. The combined lesions usually become symptomatic in the second and third decades. In all 10 cases, the angiomatous part of the combined tumors showed characteristic vascular malformation such as severe hyalinization, tortuosity, and some were even calcified. The number of abnormal blood vessels were excessive in all examples. The glial portion consisted of either astrocytoma, oligodendroglioma, or mixtures of these gliomas. Dedifferentiation of the neuroglia combined with neoplastic endothelial proliferation indicates the true neoplastic nature rather than reactive gliosis associated with a vascular anomaly.
3 Acta Neurochir (Wien). 1996;138(5):590-1.
Arteriovenous malformation associated with pleomorphic xanthoastrocytoma.Lee TT, Landy HJ, Bruce JH.
Department of Neurological Surgery, University of Miami/Jackson Memorial Hospital, FL, USA.
A case of a left temporo-occipital arteriovenous malformation associated with a pleomorphic xanthoastrocytoma is described. The patient had the vascular lesion with a stable right hemiparesis for many years prior to his recent clinical deterioration. Correlation is made with nine previously reported cases of angiogliomas. With the close proximity and temporal correlation of the two components of this lesion, as well as pathological evidence, the authors propose that angioglioma may be the product of reactive glial proliferation and transformation secondary to a pre-existing vascular malformation and hemorrhage.
4 J Neurosurg. 1991 Oct;75(4):589-66.
“Angioglioma” and the arteriovenous malformation-glioma association.Lombardi D, Scheithauer BW, Piepgras D, Meyer FB, Forbes GS.
Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.
The term “angioglioma” denotes a highly vascular glioma, most of which are low-grade lesions associated with a favorable prognosis. The authors encountered an example of this pathology, a cystic oligodendroglioma associated with prominent vasculature which both clinically and histologically mimicked an occult arteriovenous malformation (AVM). This case and reports of the association of AVM and glioma prompted a histological review of 1034 surgically resected AVM’s, both angiographically occult and visible, among which no oligodendroglial or astrocytic forms of “angioglioma” were found. Eight cases were observed, however, wherein oligodendroglial cells were increased in number within or about the malformation. Two basic histological patterns of oligodendroglial cell excess were seen; one appeared to be malformative in nature with abnormal disposition of oligodendroglial cells being an integral part of the AVM, whereas in the other an apparent increase in cellularity seemed the result of chronic ischemia with condensation of white matter. It appeared that the areas of increased oligodendrocyte content seen in association with AVM are non-neoplastic lesions that exhibit two rather distinct histological patterns of differing origin. In an effort to determine the frequency of “angioglioma,” the authors examined Tissue Registry data for several glioma groups in which highly vascular examples are prone to occur. Tumors selected for study included 104 cerebellar-type (pilocytic) astrocytomas, 82 oligodendrogliomas, and 51 supratentorial pilocytic astrocytomas. Histological hypervascularity mimicking a vascular malformation (that is, an “angioglioma”) was encountered in 5%, 4%, and 12% of the cases, respectively. Based upon clinical, radiological, and pathological reviews of these cases, as well as a careful review of the literature, it was concluded that 1) “angiogliomas” are neither rare nor represent a distinct clinicopathological entity; 2) in histological but not necessarily angiographic surgical terms, they represent simply highly vascular gliomas, usually of low grade; and 3) the clinicopathological and angiographic features as well as the prognosis of such lesions do not differ from those of similar gliomas without angioma-like vasculature. Finally, “angiogliomas” must not be confused with gliomas of high-grade malignancy which, due to neovascularity, may be highly vascular at angiography and at surgery.
5 Neurol Res. 2000 Jul;22(5):473-7.
Acquired cerebral arteriovenous malformation induced by an anaplastic astrocytoma: an interesting case.Harris OA, Chang SD, Harris BT, Adler JR.
Department of Neurosurgery, Stanford University School of Medicine, CA, USA.
High grade gliomas foster an environment rich in angiogenic factors that promote neovascularity. We report a case of a cerebral arteriovenous malformation, which developed in the setting of a high grade astrocytoma. The patient presented with complaints of confusion and left hemiparesis. An initial cerebral angiogram was normal. Repeat angiography six weeks later demonstrated an extremely vascular lesion with arteriovenous shunting involving the right thalamus and occipital lobe. Histopathologic evaluation of open biopsy and autopsy specimens demonstrated a high grade astrocytoma in association with an arteriovenous malformation. Immunohistochemical staining with VEGF was diffusely positive. A possible role for the hyperangiogenic environment of a high grade astrocytoma resulting in the development of an arteriovenous malformation is discussed.
中年男性,考虑AVM合并蛛网膜下腔出血
你好，谢谢你的评论！
对于少见病例，我认为复习一些相关的文献是必要的。对于该病例，我看到一些战友的争议点在于是用“一个病”还是“两个病”来解释，所以附上了上述关于血管畸形继发脑胶质增生和胶质瘤、及恶性脑胶质瘤继发血管畸形的文献摘要，以供大家参考。
因为目前我这里查中文文献不太方便，所以仅附了英文文献摘要；如果您能附上相关的中文文献，我会表示赞赏。
另外，上班的时间回复帖子，很遗憾我这里无法输入中文，所以有时不得不用英文表述，由此给大家带来的不便，我深表歉意。 如果你有看不懂的地方，我想你可以列出来，我相信战友们会热情给你翻译。
建议行放射治疗,伽玛刀治疗,不适用于二级或以上的胶质瘤的初程治疗.
况且从目前影象看,仍然存在脑室播散的可能性,放射治疗是恰当的后续治疗中的一环.
紫熊正解，不适合伽玛刀治疗，可以考虑放疗
同意AVM,既往蛛网膜下腔出血支持诊断,可除外肿瘤.
同意楼上各位的意见
动静脉畸形的可能性大
有没有平扫的MRI?
西门子的MRI还是不如GE的亚，呵呵
极端同意