Okuno S, Nishi N, Hirabayashi H, Sakaki T
Department of Neurosurgery, Nara Medical University, Japan.
No Shinkei Geka. 2000 Oct;28(10):891-7.
We described a surgical case of growing cavernous angioma located at the pontomedullary junction. This 52-year-old woman presented with symptoms caused by a small hemorrhage in the right cerebellopontine angle. Magnetic resonance images (MRI) suggested cavernous angioma as the underlying pathology. 9 months after the first episode, the second hemorrhage occurred with a deteriorated neurological state that disappeared under conservative treatment except for right facial paresis and hearing disturbance. During careful observation for 1 year, the size of the lesion gradually increased on MRI and additional neurological deficits including left hemiparesis and right abducent nerve palsy were diagnosed. The first operation was carried out through the right lateral suboccipital approach, but only partial removal of the cavernous angioma was accomplished due to the overlying seventh and lower cranial nerves. After more than 4 months, a third hemorrhagic episode was presented with a sudden onset of right cerebellar signs and facial numbness. The cavernous angioma grew in size to reach the ventrolateral corner of the 4th ventricle with dense hemosiderin deposition around the core lesion on MRI. An enhancement inside the lesion was also demonstrated after gadolinium-diethylenetriaminepenta-acetic acid administration. The second operation through the midline suboccipital approach was selected for the complete resection of the residual cavernous angioma. The lesion was too hard to resect without internal decompression. The pontine part of the lesion was almost totally resected, but manipulation for the medullary part to create a discrete layer between the lesion and surrounding neural tissues was unsuccessful and generated severe bradycardia, so this part of the cavernous angioma had to be left. The problems for the management of cavernous angioma in the brain stem should be discussed, especially focussing on the surgical indication in reference to our experience and previous literatures.
我们描述了一例位于脑桥延髓交界处的海绵状血管瘤的手术病例。这位52岁的女性因右侧小脑脑桥角少量出血而出现症状。磁共振成像（MRI）提示潜在病理为海绵状血管瘤。首次发病9个月后，第二次出血发生，神经状态恶化，经保守治疗后除右侧面部轻瘫和听力障碍外症状消失。在仔细观察1年期间，MRI显示病变大小逐渐增大，并诊断出包括左侧偏瘫和右侧展神经麻痹在内的其他神经功能缺损。首次手术通过右侧枕下外侧入路进行，但由于覆盖其上的第七对及更低的颅神经，仅部分切除了海绵状血管瘤。4个多月后，出现第三次出血发作，突然出现右侧小脑体征和面部麻木。海绵状血管瘤体积增大，在MRI上已延伸至第四脑室腹外侧角，核心病变周围有密集的含铁血黄素沉积。注射钆喷酸葡胺后病变内部也出现强化。第二次手术选择通过枕下中线入路以完全切除残留的海绵状血管瘤。病变质地坚硬，若无内部减压则难以切除。病变的脑桥部分几乎完全切除，但对延髓部分进行操作以在病变与周围神经组织之间形成一个分离层未成功，并引发严重心动过缓，因此不得不保留海绵状血管瘤的这部分。应讨论脑干海绵状血管瘤的治疗问题，特别是结合我们的经验和既往文献重点探讨手术指征。
