术中C型臂CT辅助经穿支动脉栓塞出血性脑深部动静脉畸形

Intraprocedural C-arm CT assisted trans-perforator embolization of deep arteriovenous malformations

目的 探讨C型臂CT辅助微导管头端定位在经穿支栓塞脑深部动静脉畸形（AVM）术中的应用.方法 回顾性分析2015年7月至2017年6月首都医科大学宣武医院神经外科收治的21例出血性脑深部AVM患者的临床资料.其中20例病变位于基底核,1例位于第四脑室.Spetzler-Martin分级4级3例,3级18例.全部患者行血管内栓塞治疗,在经穿支栓塞过程中,应用血管造影机C型臂CT功能定位微导管头端位置.结果 微导管均成功到位目标血管,无操作相关并发症.21例实施血管内栓塞49例次,经穿支栓塞37例次.经穿支栓塞过程中,应用血管造影机C型臂CT功能微导管头端定位25例次,显示微导头端22例次位于安全区域,3例次位于危险区域.术后即刻造影显示,8例畸形团完全或近全栓塞,11例病变的出血相关危险结构消失,2例畸形团部分栓塞.2例术中注胶后畸形团破裂,发生脑室出血,其中1例遗留对侧肢体麻木.12例行造影随访4～17个月,5例畸形团完全或近全栓塞者无显著变化;7例单纯栓塞出血相关危险结构者,1例畸形团完全消失,6例危险结构消失,畸形团残留.其余9例术后6个月均行门诊随访.全部患者随访期无再出血及新发神经功能障碍.结论 利用血管造影机C型臂CT功能辅助栓塞术中微导管头端定位,能够提高经穿支栓塞脑深部AVM的精确性.

 Objective To explore the application of intraprocedural C-arm CT assisted trans-perforator embolization of deep arteriovenous malformations （AVM）.Methods From July 2015 to June 2017 at Neurosurgery Department,Xuanwu Hospital Capital Medical University,a total of 21 cases of hemorrhagic deep AVM were retrospectively reviewed.There were 11 men and 10 women with the average age of 24.3 years old.Among them,20 lesions were located at the basal ganglia and 1 lesion at the fourth ventricle.Three lesions were classified as Spetzler-Martin grade 4 and 18 lesions were grade 3.All patients were treated with transarterial embolization under general anesthesia.The tip of microcatheter was localized with intraoperative C-arm CT technique when trans-perforator embolization was intended.Results Among 21 patients,a total of 49 times of embolization were performed.Twenty-five times of intraoperative C-arm CT scans were used in 37 times of trans-perforator embolization.The tip of microcatheter was positioned 22 times at the safe region and 3 times at the dangerous area.The immediate post-operative angiography revealed complete occlusion or subtotal occlusion in 8 cases,obliteration of hemorrhage-related structures in 11 and partial embolization in 2.Intraoperative ventricular hemorrhage occurred in 2 cases and 1 of them presented with numbness of contralateral extremities post embolization.Twelve cases were followed up by DSA at 4-17 months post embolization.Five lesions which were obliterated completely or subtotally developed no further changes in follow-up angiogram when compared with immediate post-operative results.In 7 lesions which were treated with obliteration of hemorrhage-related structures,the nidus of 1 lesion disappeared completely and that in 6 other lesions had residues without hemorrhage-related structures.The remaining 9 cases were clinically followed up at 6 months post embolization.Recurrent hemorrhage and new-onset neurologic deficits were not found during follow-up period.Conclusion The tip of microcatheter could be localized with the assistance of intraoperative C-arm CT technique,which might facilitate more precise trans-perforator embolization for deep AVM.