65例颅内动-静脉畸形手术疗效及技术探讨

Curative effect and surgical techniques of microsurgery for cerebral arteriovenous malformation: a report of 65 cases

目的评价手术切除颅内动.静脉畸形的有效性和安全性,并探讨手术技巧。方法 65例颅内动.静脉畸形患者,Spetzler.Martin分级Ⅰ级7例、Ⅱ级20例、Ⅲ级23例、Ⅳ级10例、Ⅴ级5例;畸形团最长径2-7 cm,平均3.50 cm;位于大脑皮质表面31例、脑深部34例,分别为额叶19例、颞叶12例、顶叶16例、枕叶9例、小脑3例、基底节2例、侧裂4例;供血动脉分别为大脑前动脉及分支11例、大脑中动脉29例、大脑后动脉15例、大脑前动脉和大脑中动脉2例,大脑前动脉和大脑后动脉5例,椎动脉3例;浅静脉引流29例、深静脉引流15例、深浅静脉同时引流21例。均予以手术切除,单纯畸形团切除术45例、畸形团切除术＋血肿清除术20例;单纯额叶入路6例、眶颧部入路3例、皮质入路2例、额顶叶入路8例、翼点入路10例、颞下入路3例、颞顶叶入路4例、单纯顶叶入路7例、纵裂入路7例、顶枕叶入路8例、枕下入路3例、皮质脑室入路4例。结果 65例患者中4例（6.15%）术前联合栓塞治疗,其中60例（92.31%）动.静脉畸形团全切除,5例（7.69%）于术后辅助立体定向放射治疗。出院时改良Rankin量表评分为0分21例（32.31%）、1分23例（35.38%）、2分9例（13.85%）、3分7例（10.77%）、4分3例（4.62%）、5分2例（3.08%）。平均随访12个月,6例恢复良好、3例肢体活动障碍、1例视野缺损、2例语言障碍、1例脑积水而行脑室.腹腔分流术、2例仍癫发作而服用抗癫药物;2例死亡,1例呼吸衰竭致死亡,1例死因不明。结论显微外科手术可有效治疗颅内动.静脉畸形,尤其是复杂动.静脉畸形,实施个体化治疗方案可有效改善患者预后。

Objective To assess the safety and efficacy of microsurgical resection of cerebral arteriovenous malformation（AVM）. Methods A total of 65 patients with cerebral AVMs were treated with microsurgical resections from April to August 2010 in our hospital. Of the 65 patients, 26 were male and39 were female with age ranging from 4 to 72 years（average 42 years）. Initial symptoms included cerebral hemorrhage in 32 cases, seizures in 10 cases, headache in 6 cases, neurological dysfunction in 14 cases,and the left 3 cases were diagnosed in health examination. According to Spetzler.Martin grades, there were7 cases in Grade Ⅰ, 20 in Grade Ⅱ, 23 in Grade Ⅲ, 10 in Grade Ⅳ and 5 in Grade Ⅴ. The diameter of nidi ranged from 2 to 7 cm（on average of 3.50 cm）. The lesions were located in the surface of cerebral cortex（31 cases） and deep brain（34 cases）, including frontal lobe（19 cases）, temporal lobe（12 cases）,parietal lobe（16 cases）, occipital lobe（9 cases）, cerebellum（3 cases）, basal ganglia（2 cases） and lateral cleft（4 cases）. Feeding arteries included anterior cerebral artery（ACA） and its branches in 11 cases,middle cerebral artery（MCA） in 29 cases, posterior cerebral artery（PCA） in 15 cases, both ACA and MCA in 2 cases, both ACA and PCA in 5 cases, and vertebral artery（VA） in 3 cases. There were superficial vein drainage in 29 cases, deep vein drainage in 15 cases, and both superficial and deep vein drainage in21 cases. All of those patients underwent surgical resections, including simple excisions in 45 cases andexcisions combined with evacuation of hematoma in 20 cases. Among all of those operations, 6 were performed through single.frontal approach, 3 orbitozygomatic approach, 2 transcortical approach, 8 frontal.parietal approach, 10 pterional approach, 3 subtemporal approach, 4 temporal.parietal approach, 7 single.parietal approach, 7 interhemispheric approach, 8 parietal.occipital approach, 3 suboccipital approach, and4 transcortical.transventricular approach. Results Among these patients, 4 cases（6.15%） had undergone prior endovascular embolization. Total resection was obtained in 60 cases（92.31%） and 5 cases（7.69%）took postoperative stereotactic radiosurgery. On discharge, modified Rankin Scale（mRS） scores were 0 in21 cases（32.31%）, 1 in 23 cases（35.38%）, 2 in 9 cases（13.85%）, 3 in 7 cases（10.77%）, 4 in 3 cases（4.62%） and 5 in 2 cases（3.08%）. During the follow.up（12 months on average）, 6 patients got good recovery, while 3 patients presented with limb weakness, one visual field defect, 2 aphasia, one underwent ventriculoperitoneal shunt（VPS） due to hydrocephalus, 2 newly occurred seizures, and 2 deaths（one died of respiratory failure after one year, and the other was agnogenic）. Conclusions Microsurgical resection of AVMs is highly efficient and can be undertaken with low rates of mortality. Adequate patient selection and careful preoperative planning are essential to improve the prognosis of patients with complicated AVM lesions.