复合手术治疗以癫痫为首发症状的儿童颅内未破裂动静脉畸形的初步观察

Preliminary observation of hybrid operation for intracranial unruptured arteriovenous malformations in children with epilepsy as the first symptom

目的初步观察以癫痫为首发症状的儿童颅内未破裂动静脉畸形(AVM)的复合手术疗效。方法回顾性分析2018年1月至2022年9月南京医科大学附属儿童医院神经外科收治的14例以癫痫为首发症状的颅内未破裂AVM患儿的临床资料。发作间期脑电图正常11例,异常3例。AVM位于额叶7例,颞叶5例,顶叶及枕叶各1例,影像学显示畸形血管团均为致密型。14例患儿均予复合手术治疗[全脑数字减影血管造影(DSA)+开颅手术切除畸形血管团];对于3例脑电图异常的AVM患儿,术中给予皮质脑电图监测,并行射频热凝或切除致痫灶。观察手术并发症。术后6~12个月复查全脑DSA;随后每年进行影像学随访,并采用改良Rankin量表评分(mRS)评价神经功能预后(mRS 0~1分为正常),同时采用Engel分级评估癫痫控制效果。结果14例患儿术中均完全切除畸形血管团。11例术前脑电图正常的患儿中,2例术中发现畸形血管团旁存在含铁血黄素沉积及胶质增生,予以切除;3例术前脑电图异常的患儿中,2例行射频热凝有效,1例行射频热凝无效而给予病灶皮质切除术。术后1例患儿出现偏瘫、失语,两周后恢复正常。14例患儿的中位随访时间为28个月(12~48个月)。至末次随访,无一例AVM复发,14例患儿的神经功能均正常,Engel分级Ⅰa级13例,Ⅱ级1例。结论初步观察发现,采用复合手术治疗以癫痫为首发症状的儿童颅内未破裂AVM的全切除率高,安全性良好,可有效控制癫痫发作。

ObjectiveTo investigate the efficacy of hybrid operation for intracranial unruptured arteriovenous malformations(AVM)with epilepsy as the first symptom in children.MethodsA retrospective analysis was conducted on the clinical data of 14 children with intracranial unruptured AVM with epilepsy as the first symptom who were admitted to the Neurosurgery Department of Children′s Hospital Affiliated to Nanjing Medical University from January 2018 to September 2022.There were 11 cases of normal and 3 cases of abnormal electroencephalogram(EEG)during the interictal phase.AVM was located in the frontal lobe in 7 cases,temporal lobe in 5 cases,and parietal and occipital lobes in 1 case each,all of which were dense.All 14 children were treated with hybrid surgery[cerebral digital subtraction angiography(DSA)and craniotomy surgery to remove AVM].For 3 cases with abnormal EEG,cortical EEG monitoring was performed during surgery,and radiofrequency thermocoagulation or resection of the epileptic focus was performed.The surgical complications were documented.DSA was performed 6 to 12 months after surgery,and annual imaging follow-up was performed.The neurological function was evaluated using the modified Rankin scale score(mRS),and the score of 0-1 in mRS was considered normal.The effectiveness of seizure control was evaluated using Engel grading system.ResultsAll 14 cases underwent complete resection of the AVM.Among the 11 cases with normal preoperative EEG,2 cases were found to have deposition of hemosiderin and glial hyperplasia adjacent to AVM during surgery,and were removed;Among the 3 cases of preoperative abnormal EEG,2 cases were treated with effective thermocoagulation,and 1 case was treated with lesion cortical resection due to ineffective thermocoagulation.One patient developed hemiplegia and aphasia after surgery,and returned to normal two weeks later.Fourteen patients were followed up for 12-48 months(median:28 months).As of the last follow-up,there was no recurrence of AVM,and the neurological function of all 14 patients was normal.There were 13 cases with Engel gradeⅠa and 1 case with gradeⅡ.ConclusionPreliminary observations have shown that using hybrid surgery to treat unruptured intracranial AVM in children with epilepsy as the initial symptom has a high cure rate and good safety.