复合手术在脑动静脉畸形破裂急诊手术中的应用

Application of compound surgery in emergency surgery of cerebral arteriovenous malformation and rupture

目的探讨复合手术在脑动静脉畸形破裂急诊手术的优越性、安全性及改善患者的预后性。方法收集2016年10月~2017年7月复合手术急诊治疗脑动静脉畸形患者共8例进行回顾性分析,均在复合手术室完成手术治疗,其中2例根据术前评估仅接受开颅切除术及术中脑血管造影,根据造影情况分次切除残余畸形团;4例接受动静脉畸形栓塞加开颅切除术,先行血管内介入栓塞,然后行动静脉畸形切除加脑内血肿清除;2例接受动静脉畸形栓塞,加脑室外引流术,术后分别于2周复查头颅MRA+MRV,6个月复查头颅CTA或DSA。结果术前GCS评分:≥8分5例,<8分3例;手术中判断病灶Spetzler分级:Ⅰ级1例,Ⅱ级2例,Ⅲ级3例,Ⅳ级1例,Ⅴ级1例。大部分栓塞5例(62.5%)。无手术死亡病例,未发生与造影相关并发症。无术后颅内出血、手术相关切口感染或颅内感染。随访6个月,复查DSA或CTA均证实畸形血管团完整切除6例,残余2例;术后发生偏瘫1例,失语1例;迟发性癫痫1例,脑积水1例。结论利用复合手术平台治疗脑AVM,明显节省手术时间、增加手术全切率、降低手术相关并发症,改善患者预后,提高患者生存质量,减轻社会及家庭经济负担。

Objective To investigate the superiority and safety of compound surgery in emergency surgery of cerebral arteriovenous malformation and rupture, and its prognosis of improvement. Methods A total of 8 patients with cerebral arteriovenous malformation（AMV） who were given combined emergency surgery from October 2016 to July 2017 were retrospectively collected. All the patients were given the surgery in the compound operation room. Two of them were only given craniotomy and intracranial angiography according to the preoperative assessment. According to angiography, the residual deformity groups were dissected in batches; 4 cases were given arteriovenous malformation embolism com- bined with craniotomy. Interventional endovascular embolization was carried out first before the arteriovenous malfor- mation dissection plus cerebral hematoma removal was given; 2 cases were given arteriovenous malformation embolism, plus external ventricular drainage. After 2 weeks, the cranial MRA＋MRV was reviewed after the surgery, and the cra- nial CTA or DSA was reviewed after 6 months. Results Preoperative GCS score： ≥ 8 points in 5 cases, and 〈8 points in 3 cases; the Spetzler grading of lesions was judged in the surgery： 1 case in grade Ⅰ, 2 cases in grade Ⅱ,3 cases in grade Ⅲ, 1 case in grade Ⅳ and 1 case in grade Ⅴ. Most embolisms were in 5 cases （62.5%）. No surgical deaths were detected, no complications related to angiography were seen, and no postoperative intracranial hemorrhage, surgical incision-related infection or intracranial infection were observed. The patients were followed up for 6 months, and re- tests of DSA or CTA confirmed the complete removal of malformation vascular mass was in 6 cases, and residue in 2 cases; postoperative hemiplegia was in 1 case, and aphasia was in 1 case; delayed epilepsy was in 1 case, and hydro- cephalus was in 1 case. Conclusion The treatment of brain AVM by using the composite surgical platform can signifi- cantly save the operation time, increase the total resection rate, reduce the operation-related complications, improve the prognosis of patients, improve the quality of life and lessen the financial burden on the society and the family.