复杂脑动静脉畸形的显微外科手术治疗效果分析

Efficacy analysis on microsurgery for complicated intracranial arteriovenous malformations

目的 探讨显微外科手术治疗复杂脑动静脉畸形的诊治要点。方法 回顾性分析苏州大学附属第一医院神经外科2011年1月—2021年1月通过单纯显微手术切除及复合手术治疗的38例复杂脑动静脉畸形患者的临床资料,根据Spetzler-Martin分级,Ⅲ级24例,Ⅳ级9例,Ⅴ级5例。畸形血管团平均大小为5.9 cm(3.5~12.3 cm),位于功能区27例,非功能区11例,术前行CTA、DSA及MRI检查,术后行CT、CTA或DSA检查,定期随访,格拉斯哥预后评分(GOS)评价神经功能障碍。结果 所有患者中,28例接受介入加手术综合治疗,10例接受单纯显微手术切除。术后影像学示,35例(92.1%)全切,3例(7.9%)较术前明显缩小。术后随访6~79个月,其中恢复良好34例(GOS=4~5分),中度残障2例(GOS=3分),重度残障1例(GOS=2分),死亡1例(GOS=1分)。结论 显微外科手术切除是治疗复杂脑动静脉畸形的有效方法之一,通过和血管内介入栓塞紧密结合,加之术前精准影像学评估,术中导航、荧光血流监测技术的应用及术中科学的显微操作,均是手术成功的关键。

Objective To explore the diagnosis and treatment of complex cerebral arteriovenous malformations by microsurgery. Methods The clinical data of 38 patients with complex cerebral arteriovenous malformations treated by simple microsurgery and combined surgery in the neurosurgery department of the First Affiliated Hospital of Soochow University from January 2011 to January 2021 were analyzed retrospectively, with 24 cases of grade Ⅲ, 9 cases of grade Ⅳ, and 5 cases of grade Ⅴ, according to Spetzler-Martin classification. The mean size of the malformed vascular mass was 5.9 cm(3.5-12.3 cm), located in the functional area in 27 cases and the non-functional area in 11 cases. CTA, DSA, and MRI were performed preoperatively, and CT, CTA or DSA were performed postoperatively. The neurological deficits were evaluated by the Glasgow prognostic score(GOS) at regular follow-up. Results In all cases, 28 underwent combined surgical treatment, and 10 underwent simple microsurgical resection. Postoperative imaging showed total resection in 35(92.1%) and a significant reduction from a preoperative level in 3(7.9%). Postoperative follow-up was 6-79 months, with good recovery in 34(GOS=4~5 points), moderate disability in 2(GOS=3 points), severe disability in 1(GOS=2 points), and death in 1(GOS=1 point). Conclusions Microsurgical resection is one of the effective methods for the treatment of complex cerebral arteriovenous malformations. The combination of preoperative imaging, preoperative supply artery embolization, intraoperative navigation, electrophysiological monitoring, and fine intraoperative microscopic manipulation is the key to successful surgery.