摘要目的:探讨单纯血管内栓塞治疗高级别(Spetzler-Martin分级Ⅲ~V级)颅内动静脉畸形(AVM)的安全性及有效性。方法:回顾性收集2015年1月至2024年10月南京大学医学院附属金陵医院神经外科收治的139例高级别颅内AVM患者的临床资料，根据治疗策略、治疗时期分为联合治疗组(血管内栓塞联合显微外科手术治疗，35例)、前期栓塞组(2015—2020年接受单纯血管内栓塞治疗，37例)和近期栓塞组(2021—2024年接受单纯血管内栓塞治疗，67例)。为减少混杂偏倚，采用倾向性评分匹配法，分别对前期栓塞组与近期栓塞组、联合治疗组与近期栓塞组相关指标进行组间对比分析，以分别评估"技术进步"和"治疗策略"两个独立维度对疗效和安全性的影响。同时，对比分析近期栓塞组内接受单次栓塞与分次栓塞治疗患者的相关指标的差异。主要观察指标包括治愈率、永久性功能障碍发生率、术后并发症发生率及改良Rankin量表(mRS)评分(mRS评分增加为恶化，0~2分为预后良好)等。结果:完成倾向性评分匹配后，与前期栓塞组比较，近期栓塞组患者的治愈率高[80.8%(21/26)对比42.3%(11/26)]、永久性功能障碍发生率低[15.4%(4/26)对比42.3%(11/26)]、栓塞次数多[ M( Q1， Q3)：1(1，2)次对比1(1，1)次]，差异均有统计学意义(均 P<0.05)；两组患者的术后并发症发生率、出院前mRS评分恶化率等差异均无统计学意义(均 P>0.05)。完成倾向性评分匹配后，与联合治疗组比较，近期栓塞组颅内AVM位于深部者占比高[32.1%(9/28)对比3.6%(1/28)]、术后并发症发生率低[25.0%(7/28)对比57.1%(16/28)]，差异均有统计学意义(均 P<0.05)；而两组患者的治愈率、永久性功能障碍发生率、出院前mRS评分恶化率等差异均无统计学意义(均 P>0.05)。近期栓塞组中亚组分析显示，分次栓塞与单次栓塞组间患者的治愈率、术后并发症发生率、预后良好者占比等差异均无统计学意义(均 P>0.05)。122例患者获得临床及影像学随访，中位随访时间为5个月(3~48个月)；末次随访时119例(97.5%)患者的mRS评分不变或下降，联合治疗组、前期栓塞组、近期栓塞组中预后良好者占比分别为60.0%(21/35)、56.8%(21/37)、77.6%(52/67)。 结论:随着技术进步，单纯血管内栓塞治疗高级别颅内AVM治愈率和安全性显著提高，近期疗效已优于前期阶段，并与联合手术治疗效果相当，且并发症更少。对于部分患者，分次栓塞策略具有安全性和可行性，为高级别颅内AVM的治疗提供了新的有效选择。

abstractsObjective:To investigate the efficacy and safety of endovascular embolization as therapy in high-grade (Spetzler-Martin grade Ⅲ-Ⅴ) intracranial arteriovenous malformation (AVM).Methods:A retrospective analysis was conducted on the clinical data of 139 patients with high-grade intracranial AVM from January 2015 to October 2024 in the Department of Neurosurgery, the Affiliated Jinling Hospital of Nanjing University Medical School. According to the treatment strategy or treatment period, patients were divided into the combined treatment group (receiving embolization combined with microsurgical treatment, 35 cases), the early embolization group (receiving embolization treatment alone from 2015 to 2020, 37 cases), and the recent embolization group (receiving embolization treatment from 2021 to 2024, 67cases). To reduce confound bias, the propensity score matching (PSM) method was adopted to conduct inter-group comparative analyses of the early embolization and the recent embolization, as well as between the combined treatment and the recent embolization, in order to respectively evaluate the influence on efficacy and safety of the "technological progress" and "treatment strategy". Meanwhile, a comparative analysis was conducted on the patients who received single embolization and staged embolization treatment. The main observation indicators included the cure rate, the incidence of permanent dysfunction, postoperative complications and modified Rankin Scale (mRS) score (an increase in score of mRS indicating deterioration, and a score of 0 to 2 indicating good prognosis).Results:After PSM, the patients in the recent embolization group had a higher cure rate [80.8%(21/26) vs. 42.3%(11/26)], a lower rate of permanent dysfunction [15.4%(4/26) vs. 42.3%(11/26)], and more embolization times [ M( Q1, Q3): 1 (1, 2) times vs. 1 (1, 1) times] than the early embolization group, and the differences were all statistically significant (all P<0.05). There were no statistically significant differences in the incidence of postoperative complications or the deterioration rate of mRS score before discharge between the two groups of patients (both P>0.05). After PSM, compared with the combined treatment group, the proportion of patients with deep intracranial AVM in the recent embolization group was higher [32.1%(9/28) vs. 3.6%(1/28)], and the incidence of postoperative complications was lower [25.0%(7/28) vs. 57.1%(16/28)], and the differences were statistically significant (both P<0.05). However, there were no statistically significant differences in the cure rate, the rate of permanent dysfunction, or the deterioration rate of mRS score before discharge (all P>0.05). There were no statistically significant differences in the cure rate, the incidence of postoperative complications, or the proportion of patients with good prognosis between the staged embolization group and the single embolization group in the recent embolization group (all P>0.05). A total of 122 patients were followed up clinically and radiologically, and the median follow-up time was 5 months (ranged from 3 to 48 months). At the last follow-up, 119 cases (97.5%) had stable or improved mRS scores. The proportions of patients with good prognosis in the combined treatment group, the early embolization group, and the recent embolization group were 60.0% (21/35), 56.8% (21/37) and 77.6% (52/67), respectively. Conclusions:With the advancement of technology, the cure rate and safety of endovascular embolization alone for high-grade intracranial AVM have significantly improved. The short-term efficacy seems superior to that of the early stage and comparable to that of combined surgical treatment, with fewer complications. For some patients, the staged embolization strategy is safe and feasible, providing a new and effective option for the treatment of high-grade intracranial AVM.