Aldea Sorin, Consoli Arturo, Rodesch Georges, Gaillard Stephan
Department of Neurosurgery, Foch Hospital, Suresnes, France.
Department of Neuroradiology, Foch Hospital, Suresnes, France.
Oper Neurosurg (Hagerstown). 2020 Jan 1;18(1):E14-E15. doi: 10.1093/ons/opz060.
Arteriovenous malformations (AVM) of the medial surface of the cerebral hemispheres are challenging because of the limited access to the interhemispheric fissure, the presence of the bridging veins, and the difficult control of arterial feeders and deep venous drainage. We present a 20-yr-old patient with a grade 3 Spetzler Martin ruptured right medial parietal AVM revealed by headaches, left hemiparesis, and ataxia. We highlight the importance of a detailed and selective study of AVM angioarchitecture with new sequences as XperCT (Philips Medical) viewing which permits a better understanding of the anatomy and pathology and a better therapeutical planning. Selective embolization of arterial feeders with Glubran2 (GEM) allows a better control of selected sectors of the AVM which may be difficult to access at surgery. This type of planning is especially important when the AVM is in close relationship with an important sulcus, as was the case of this patient whose AVM was adherent to the postcentral sulcus. We present the surgical nuances concerning patient positioning, craniotomy, AVM dissection, and resection. Early identification and interruption of the main arterial feeders facilitate further dissection. We discuss the timing of deep venous drainage interruption in AVMs with mixed superficial and deep venous drainage. The postoperative course was favorable and the postoperative angiogram showed complete resection of the AVM. At the last follow-up, the patient had only slight left ataxia. Multimodal management with planned selective embolization may facilitate microsurgical resection of AVMs. Given the retrospective nature of this report, informed consent was not required.
由于进入大脑半球间裂的通道有限、存在桥静脉以及难以控制动脉供血支和深部静脉引流，大脑半球内侧面的动静脉畸形（AVM）的治疗颇具挑战性。我们报告了一名20岁的患者，因头痛、左侧偏瘫和共济失调被诊断为3级斯佩茨勒-马丁分级的右侧顶叶内侧AVM破裂。我们强调了使用新序列如XperCT（飞利浦医疗）进行详细且选择性的AVM血管结构研究的重要性，这有助于更好地理解解剖结构和病理情况，并制定更好的治疗方案。使用Glubran2（GEM）对动脉供血支进行选择性栓塞，可以更好地控制AVM中一些手术中难以触及的区域。当AVM与重要脑沟关系密切时，这种规划尤为重要，本病例中的AVM就附着于中央后沟上。我们介绍了有关患者体位、开颅手术、AVM分离和切除的手术细节。早期识别并阻断主要动脉供血支有助于进一步分离。我们讨论了在浅表和深部静脉混合引流的AVM中，深部静脉引流阻断的时机。术后病程顺利，术后血管造影显示AVM完全切除。在最后一次随访时，患者仅遗留轻微的左侧共济失调。采用计划性选择性栓塞的多模式治疗可能有助于AVM的显微手术切除。鉴于本报告的回顾性性质，无需获取知情同意。
