Barone Damiano G, Marcus Hani J, Guilfoyle Mathew R, Higgins J Nicholas P, Antoun Nagui, Santarius Thomas, Trivedi Rikin A, Kirollos Ramez W
Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK.
Department of Neuroradiology, Adden-brooke's Hospital, Cambridge, UK.
Neurosurgery. 2017 Jul 1;81(1):75-86. doi: 10.1093/neuros/nyx003.
Management of ruptured arteriovenous malformations (AVMs) with a mass-producing intracerebral hematoma (ICH) represents a surgical dilemma.
To evaluate the clinical outcome and obliteration rates of microsurgical resection of AVM when performed concomitantly with evacuation of an associated space-occupying ICH.
Data of patients with AVM were collected prospectively. Cases were identified in which an AVM was resected and an associated space-occupying ICH was evacuated at the same time, and divided into "group 1," in which the surgery was performed acutely within 48 h of presentation (secondary to elevated intracranial pressure); and "group 2," in which selected patients were operated upon in the presence of a liquefying ICH in the "subacute" stage. Clinical outcomes were assessed using the modified Rankin Scale, with a score of 0 to 2 considered a good outcome. Obliteration rates were assessed using postoperative angiography.
From 2001 to 2015, 131 patients underwent microsurgical resection of an AVM, of which 65 cases were included. In "group 1" (n = 21; Spetzler-Ponce class A = 13, class B = 5, and class C = 3), 11 of 21 (52%) had a good outcome and in 18 of 19 (95%) of those who had a postoperative angiogram the AVMs were completely obliterated. In "group 2" (n = 44; Spetzler-Ponce class A = 33, class B = 9, and class C = 2), 31 of 44 (93%) had a good outcome and 42 of 44 (95%) were obliterated with a single procedure. For supratentorial AVMs, the ICH cavity was utilized to provide an operative trajectory to a deep AVM in 11 cases, and in 26 cases the ICH cavity was deep to the AVM and hence facilitated the deep dissection of the nidus.
In selected patients the presence of a liquefying ICH cavity may facilitate the resection of AVMs when performed in the subacute stage resulting in a good neurological outcome and high obliteration rate.
伴有大量脑内血肿（ICH）的破裂动静脉畸形（AVM）的治疗是一个手术难题。
评估在清除相关占位性ICH的同时进行AVM显微手术切除的临床结果和闭塞率。
前瞻性收集AVM患者的数据。确定同时进行AVM切除和清除相关占位性ICH的病例，并分为“1组”，即发病48小时内急诊手术（继发于颅内压升高）；“2组”，即部分患者在“亚急性”期液化性ICH时进行手术。使用改良Rankin量表评估临床结果，评分0至2视为良好结果。使用术后血管造影评估闭塞率。
2001年至2015年，131例患者接受了AVM显微手术切除，其中65例纳入研究。在“1组”（n = 21；Spetzler-Ponce A级 = 13例，B级 = 5例，C级 = 3例）中，21例中有11例（52%）结果良好，19例中有18例（95%）术后血管造影显示AVM完全闭塞。在“2组”（n = 44；Spetzler-Ponce A级 = 33例，B级 = 9例，C级 = 2例）中，44例中有31例（93%）结果良好，44例中有42例（95%）一次手术即实现闭塞。对于幕上AVM，11例利用ICH腔提供到达深部AVM的手术路径，26例中ICH腔位于AVM深部，从而便于对病灶进行深部解剖。
对于部分患者，在亚急性期手术时，液化性ICH腔可能有助于AVM切除，从而获得良好的神经功能结果和高闭塞率。
