Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
World Neurosurg. 2020 Jul;139:582. doi: 10.1016/j.wneu.2020.04.197. Epub 2020 May 4.
A 49-year-old woman presented with sudden-onset headache and meningismus. Computed tomography scan revealed a posterior fossa subarachnoid hemorrhage extending from the foramen magnum to the ambient cistern. Angiography showed a pial extramedullary arteriovenous malformation (AVM) at the lateral ventral surface of the cervicomedullary junction with primary supply from the left posterior inferior cerebellar artery (PICA) and dominant drainage into the anterior median perimedullary vein. Embolization of the AVM was considered a high-risk procedure, as feeding arteries originated from the proximal lateral medullary segment of the left PICA. A far lateral approach with suboccipital craniotomy and C1-C2 laminectomy was performed (Video 1). The PICA was disconnected from the AVM, and multiple small feeders were interrupted with bipolar cautery and aneurysm clips to achieve an in situ occlusion of the pial AVM. Intraoperative indocyanine green video angiography was used to define the AVM and critical en passant vessels before disconnection and to demonstrate no residual early venous filling after the in situ occlusion. Postoperative angiography demonstrated no residual arteriovenous shunting or nidiform vessels, with preservation of patency of the left PICA. The patient had an uneventful postoperative course and was discharged with no significant neurologic deficits.
一位 49 岁女性因突发头痛和脑膜刺激征就诊。计算机断层扫描显示后颅窝蛛网膜下腔出血，从枕骨大孔延伸至环池。血管造影显示颈髓交界处外侧腹侧表面有软膜外动静脉畸形（AVM），主要由左侧小脑后下动脉（PICA）供应，主要引流至前正中软膜旁静脉。由于供血动脉起源于左侧 PICA 的近端外侧延髓段，因此栓塞 AVM 被认为是一种高风险的手术。行远外侧入路，行枕下颅骨切开术和 C1-C2 椎板切除术（视频 1）。PICA 与 AVM 分离，用双极电凝和动脉瘤夹夹闭多个小的供血动脉，以实现软膜 AVM 的原位闭塞。术中吲哚菁绿视频血管造影用于在分离前定义 AVM 和关键的顺行血管，并在原位闭塞后显示无早期静脉充盈残留。术后血管造影显示无残留动静脉分流或 nidiform 血管，左侧 PICA 通畅。患者术后无并发症，无明显神经功能缺损出院。
