Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, São Paulo, Brazil.
Department of Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, São Paulo, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo, São Paulo, Brazil.
World Neurosurg. 2022 Jul;163:37. doi: 10.1016/j.wneu.2022.04.006. Epub 2022 Apr 9.
Arteriovenous malformations (AVMs) are complex, heterogeneous, and uncommon neurovascular disorders that frequently manifest in young adults. Parenchymal AVMs are thought to be congenital, but this has been recently questioned in the literature. AVMs can change over time and cause focal neurological signs or neurocognitive deficits. The clinical presentation of an AVM is variable and depends mainly on the occurrence of bleeding as well as its location, size, and ability to take flow from adjacent areas. AVMs can be treated by a single modality or a combination of different modalities. According to the Expert Consensus on the Management of Brain Arteriovenous Malformations, neurosurgery may be the best option for Spetzler-Martin grade 2 AVMs. However, the treatment of these lesions when located in eloquent areas, especially in the central lobe, is controversial. Awake craniotomy allows identification of eloquent gyrus and can potentially facilitate resection with functional preservation. An alternative is stereotactic radiosurgery, but a qualitative comparative analysis revealed higher obliteration rate with awake AVM excision compared with stereotactic radiosurgery. Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. It was used in the past for surgical management of intractable epilepsy, but its indications are increasing, and it is a widely recognized technique for resection of mass lesions involving the eloquent cortex and for deep brain stimulation. Its application for resection of vascular lesions, including AVMs, is still limited. In the Video, we present a case of a cerebral AVM of the precentral gyrus in which we achieved complete resection with awake microsurgical treatment without any neurological sequelae for the patient.
动静脉畸形（AVM）是一种复杂、异质且不常见的神经血管疾病，常发生于年轻人。人们认为实质型 AVM 是先天性的，但这一点在最近的文献中受到了质疑。AVM 会随时间变化，并导致局灶性神经体征或神经认知缺陷。AVM 的临床表现多种多样，主要取决于出血的发生以及其位置、大小和从邻近区域获取血流的能力。AVM 可以通过单一方式或多种方式联合治疗。根据《脑动静脉畸形管理专家共识》，对于 Spetzler-Martin 分级 2 的 AVM，神经外科可能是最佳选择。然而，当这些病变位于功能区，特别是中央叶时，其治疗存在争议。清醒开颅术可以识别功能区脑回，并有可能在保留功能的情况下进行切除。另一种选择是立体定向放射外科，但一项定性比较分析显示，清醒 AVM 切除的闭塞率高于立体定向放射外科。清醒开颅术是最早已知的手术程序，它再次流行起来。过去，它曾用于治疗难治性癫痫，但现在其适应证正在增加，它是切除涉及功能区皮质的肿块病变和深部脑刺激的广泛认可的技术。其在血管病变（包括 AVM）切除中的应用仍然有限。在该视频中，我们展示了一例中央前回脑 AVM 病例，我们通过清醒显微手术治疗实现了完全切除，患者无任何神经后遗症。
