脑动静脉畸形的综合血管内和开放性手术治疗
Summary
手术是 arteriovenious 畸形 (车辆) 的金标准, 术前栓塞可以简化这一过程。我们描述我们的方法进行分期血管内栓塞和开放切除车辆, 并提供一个有代表性的临床例子突出的优势, 全面训练的神经血管外科医生领导的多学科临床团队.
Abstract
Arteriovenious 畸形 (车辆) 与显著的发病率和死亡率相关, 并有每年3% 的破裂风险。治疗车辆必须专门针对病变, 手术切除是金标准的小, 容易接近的病变。预手术栓塞车辆可以减少尼达尔血流量, 消除高危的 AVM 功能, 如 intranidal 或静脉动脉瘤, 从而简化了一个具有挑战性的神经外科手术。在此, 我们描述了我们的方法进行分期血管内栓塞和开放切除车辆, 并强调了优势, 有全面训练的神经血管外科医生领导一个多学科的临床团队。这包括计划开颅手术和切除术, 立即跟随最后的栓塞阶段, 从而使用一个单一的麻醉期, 积极栓塞, 并迅速切除。最后, 我们提供了一个有代表性的情况下, 22-year-old 女性与破裂右额动静脉畸形诊断在癫痫发作检查, 谁成功治疗通过分期栓塞后, 开放手术切除。
Introduction
脑动静脉畸形 (车辆), 动脉和静脉之间的异常连接不干预正常毛细血管床, 目前独特的神经外科的挑战。根据大小, 存在深引流静脉, 并参与雄辩皮质,1出血的风险以前破裂车辆范围从0.9 到8% 每年,2 , 每年平均破裂风险为3%。3车辆的出血与近10% 的死亡率和显著的发病率有关, 其中多达34% 的患者有中度至严重残疾。4先前破裂的车辆增加了年出血率,2 , 但复的即时风险相对较低。除非血肿的质量影响需要急性干预, 否则治疗通常是在权衡了预期的自然病史与治疗相关的风险之后进行的。5,6
外科手术切除是治疗选择的小车辆, 因为它立即和明确地消除未来出血的风险。然而, 高流速的车辆, 以及增加风险的 AVM 相关动脉瘤,4,7 , 使外科手术切除最具挑战性的所有神经外科病例。术前栓塞车辆, 以减少血流量和消除高危 AVM 的特点, 可以大大减少技术挑战的切除。
综合训练的血管外科是唯一的定位, 以明确治疗车辆通过进行术前血管造影和血管内栓塞, 以及开放手术切除。在这里, 我们描述的管理协议的外科手术可及性脑车辆 (根据确定的评分等级1,8以及外科医生和多学科会议评价) 在我们的机构。
Protocol
根据机构指南获得知情同意后, 以下所述的所有程序均作为脑车辆患者的护理标准执行. 1. 初始患者评估和成像 注意: 破裂车辆的患者通常在畸形被发现后出现在头痛或癫痫检查的影像上。车辆破裂的患者经常出现头痛、恶心、呕吐、虚弱、麻木和/或视力变化的急性发作. 通过访问患者和/或家庭 (以确定以前的破裂状态、家族病史) 和执行详?…
Representative Results
一个 22-year-old 前健康女性提出新的发作发作。非对比头颅 CT 对急性出血呈阴性, 但表现为右额病变不完全特征。MRI 显示在右上额脑回 (图 1) 内有大约 2.9 x 2.4 cm Spetzler-马丁级 3 AVM, 有大量引流皮质静脉到上矢状窦, 通过右大分支的动脉供血大脑中动脉病人进行了多次分期血管内栓塞, 最终在栓塞的右脑前动脉蒂 (图 2)。在完成这些分期栓塞有剩余供…
Discussion
在这里, 我们展示了一个综合的方法, 脑车辆通过联合血管内和开放式手术管理。导管血管造影是成像车辆的金标准, 对手术评估和规划具有重要的价值。手术前栓塞可以简化手术切除, 但需要与外科和介入治疗组之间的沟通, 以制定一个最佳的战略方法。例如, AVM 动脉馈线最容易栓塞也可能是最外科手术。然而, 如果他们是栓塞之前制定一个全面的治疗计划, 只留下更深更难获得动脉馈线, 手术变得…
Disclosures
The authors have nothing to disclose.
Acknowledgements
作者感谢所有的临床团队每天对 UCSD 的 AVM 患者的护理。
Materials
| ChloraPrep Sterilization Solution | BD, Franklin Lakes, NJ | 260815 | For skin sterilization |
| Lidocaine Hcl 1% | ACE Surgical Supply, Inc, Brockton, MA | 001-1421 | For local anesthetic |
| Micropuncture Groin Access Kit | Cook Medical, Bloomington, IN | G56202 | Used for femoral artery access |
| 0.035 Guidewire | Terumo Medical, Somerset, NJ | GR3506 | Used in conjunction with diagnostic catheters for cerebral angiography |
| Cerebral Angiography Diagnostic Catheters | Terumo Medical, Somerset, NJ | CG416 | Used in conjunction with guidewire for cerebral angiography |
| Omnipaque Contrast Agent | GE Healthcare, Chicago, IL | Q9965 | Contrast agent for cerebral vessel imaging |
| Microcatheter and Microwire | Covidian, Plymouth, MN | 105-5091-150, 103-0608 | Used for distal arterial catheterization |
| Onyx Liquid Embolic | Covidian, Plymouth, MN | 105-7100-060 | Used for AVM embolization |
| Angio-Seal Vascular Closure Device | St. Jude Medical, St Paul, MN | 610130 | Used for femoral artery closure following angiography/intra-arterial embolization |
| Midas Rex High Power Drill System | Medtronic, Minneapolis, MN | PM700 | Used for craniotomy |
| Matchstick Drill Bit | Medtronic, Minneapolis, MN | 10MH30-MN | Used to create burr hole for craniotomy |
| Tapered Drill Bit | Medtronic, Minneapolis, MN | F1/8TA15 | Used to complete craniotomy |
| #11 and 15 Blade Surgical Scalpels | BD Bard-Parker, Franklin Lakes, NJ | 372615 | Used for groin incision for angiography and dural opening for external ventricular drain placement or AVM resection |
| Metzenbaum Dissecting Scissors | Stoelting Co, Wood Dale, IL | 52134-01P | Used for dural opening |
| Bone Elevator | Stoelting Co, Wood Dale, IL | 52169 | Used for separating dura from the inner skull |
| Gerald Forceps | Stoelting Co, Wood Dale, IL | 52106-52 | Used for dural opening and manipulation |
| Microsurgical Instruments | Accurate Surgical & Scientific Instruments Corporation, Westbury, NY | ASSI.BML1 | Used for AVM microsurgical resection |
| Bipolar Forceps | Accurate Surgical & Scientific Instruments Corporation, Westbury, NY | ASSI.BPNS20423FP | Used for AVM microsurgical resection |
| Electrosurgery Generator | Bovie Medical Products, Clearwater, FL | IDS-200 | Used for electrosurgical cutting/coagulation |
| Small Aneurysm Clips | Codman Neuro, Raynham, MA | 20-1801 | Used for occlusion of arterial AVM feeders not amenable to coagulation |
| Brain Retractors | Medicon, Tuttlingen, Germany | 22.00.06 | For brain retraction for deep AVM dissection/resection |
| Variable Action Suction tip | Millennium Surgical, Narberth, PA | 6-8607 | For suction with AVM dissection/resection |
| Fibrillar Absorbable Hemostatic Agent | Ethicon, Somerville, NJ | 63713-0019-61 | For hemostatis within surgical cavity |
| 4-0 Suture | Ethicon, Somerville, NJ | C554D | For dural closure |
| 2-0 Absorbable Suture | Ethicon, Somerville, NJ | J286G | For deep tissue closure |
| 3-0 Nylon Suture | Ethicon, Somerville, NJ | ET-663G | For skin closure |
| Surgical Staples | Medline, Mundelein, IL | STAPLER35RB | For skin closure |
| Bone Plating System | Biomet, Warsaw, IN | 15-7378-12 | For bone flap securement |
| Operating Microscope | Leica Microsystems, Buffalo Grove, IL | M720 OH5 | Used for AVM microsurgical resection |
| BrainLab Neuronavigation Imaging System | Brainlab, Inc, Chicago, IL | Brainlab Curve | Used for AVM microsurgical resection |
| Lumbar External Drainage System | Codman Neuro, Raynham, MA | K964923 | Used for placement of lumbar drain for CSF drainage |
| External Ventricular Drainage Catheter | Medtronic, Minneapolis, MN | Used for placement of ventricular catheter for CSF drainage | |
| Disposable Raney Scalp Clips | A&E Medical Corporation, Farmingdale, NJ | 070-001 | Used for scalp hemostasis |
References
- Spetzler, R. F., Martin, N. A. A proposed grading system for arteriovenous malformations. J Neurosurg. 65 (4), 476-483 (1986).
- Stapf, C., et al. Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology. 66 (9), 1350-1355 (2006).
- Kondziolka, D., McLaughlin, M. R., Kestle, J. R. Simple risk predictions for arteriovenous malformation hemorrhage. Neurosurgery. 37 (5), 851-855 (1995).
- Fukuda, K., et al. Multicenter assessment of morbidity associated with cerebral arteriovenous malformation hemorrhages. J Neurointerv Surg. , (2016).
- Conger, A., Kulwin, C., Lawton, M. T., Cohen-Gadol, A. A. Endovascular and microsurgical treatment of cerebral arteriovenous malformations: Current recommendations. Surg Neurol Int. 6, (2015).
- Mohr, J. P., et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 383 (9917), 614-621 (2014).
- Crawford, P. M., West, C. R., Chadwick, D. W., Shaw, M. D. Arteriovenous malformations of the brain: natural history in unoperated patients. J Neurol Neurosurg Psychiatry. 49 (1), 1-10 (1986).
- Lawton, M. T., Kim, H., McCulloch, C. E., Mikhak, B., Young, W. L. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 66 (4), 702-713 (2010).
- Hemphill, J. C., et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 46 (7), 2032-2060 (2015).
- Gross, B. A., Frerichs, K. U., Du, R. Sensitivity of CT angiography, T2-weighted MRI, and magnetic resonance angiography in detecting cerebral arteriovenous malformations and associated aneurysms. J Clin Neurosci. 19 (8), 1093-1095 (2012).
- Hashimoto, T., Young, W. L. Anesthesia-related considerations for cerebral arteriovenous malformations. Neurosurg Focus. 11 (5), 5 (2001).
- Seldinger, S. I. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta. 39 (5), 368-376 (1953).
- Abando, A., Hood, D., Weaver, F., Katz, S. The use of the Angioseal device for femoral artery closure. J Vasc Surg. 40 (2), 287-290 (2004).
- Deshaies, E. M., et al. Multimodality intraoperative neurophysiological monitoring during Onyx embolization of cerebrovascular malformations. Neurodiagn J. 55 (1), 12-24 (2015).
- Viñuela, F., et al. Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases. J Neurosurg. 75 (6), 856-864 (1991).
Cite This Article
Rennert, R. C., Steinberg, J. A., Cheung, V. J., Santiago-Dieppa, D. R., Pannell, J. S., Khalessi, A. A. Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations. J. Vis. Exp. (128), e55522, doi:10.3791/55522 (2017).