脊髓髓内动静脉畸形的复合手术治疗

目的 探讨脊髓髓内动静脉畸形（IAVMs）的临床特点以及复合手术的临床疗效。方法 回顾性分析2017年9月至2021年6月在复合手术室行显微手术治疗的7例IAVMs的临床资料。先行DSA定位,显微镜下完全显露畸形血管团,术中DSA美兰实时显影技术精准判断供血动脉、引流静脉。结果 7例均顺利完成手术,其中6例畸形血管团全切除,术后即刻DSA显示供血动脉、畸形血管团、引流静脉不显影;1例胸段IAVM因部分病灶深入脊髓腹侧,在阻断供血动脉及引流静脉后仅进行部分切除。7例术后随访9~54个月,平均（27.7±16.5）个月;术后9个月McCormick分级Ⅰ级2例,Ⅱ级2例,Ⅲ级1例,Ⅳ级2例;末次随访,7例症状均改善,无死亡病例;除部分切除的1例外,其余6例复查MRI未见迂曲血管影及畸形血管团。结论 IAVMs临床少见。在电生理监测下,运用术中DSA美兰实时显影辅助显微手术切除IAVMs,可取得较好的临床疗效。     

复合手术治疗髓内复杂动静脉畸形1例并文献复习

目的 探讨复合手术治疗髓内复杂动静脉畸形（AVM）的临床效果。方法 回顾性分析2016年2月采用复合手术治疗的1例髓内复杂AVM的临床资料,并结合相关文献进行分析。结果 术中结合荧光引导,显微手术配合血管内栓塞,电凝切断表浅及可以显露的供血动脉,对深部难以显露的供血动脉和畸形团进行栓塞,切除其余可以显露的具有占位效应的大部分畸形血管团。术后DSA造影显示畸形团闭塞满意,病人症状缓解。结论 复合手术治疗髓内复杂型AVM安全、有效。     

脑动静脉畸形手术,栓塞及栓塞加手术治疗的临床研究

目的通过对８３例脑动静脉畸形（ＡＶＭ）分别进行直接手术,单纯栓塞或栓塞加手术治疗的比较研究,探讨治疗ＡＶＭ的理论有效方案。方法（１）直接手术２４例,病人按Ｓｐｅｔｚｌｅｒ－Ｍａｒｔｉｎ分级（Ｓ－Ｍ）Ⅰ级１０例,Ⅱ级８例,Ⅲ级５例,Ⅳ级１例,Ⅲ级以上６例占２５％,急诊手术１０例,显向手术１４例,（２）３６例行单纯超选择微导管栓塞（ＮＢＣＡ或真丝线段）,Ｓ－ＭⅡ级１６例,Ⅲ级１４例,Ⅳ级６例,Ⅲ级以上     

血管内栓塞治疗脑动静脉畸形

目的探讨血管内栓塞治疗脑动静脉畸形(AVM)的临床意义。方法应用血管内栓塞治疗脑AVM 37例,栓塞剂为NBCA或(和)ONYX,栓塞后11例行γ-刀治疗。结果畸形血管团完全消失6例,消失90％以上11例,70％～90％17例,70％以下3例。栓塞后2例发生灌注压突破出现脑肿胀,另2例发生脑出血。结论血管内栓塞治疗脑AVM的方法是安全的,可治愈部分脑 AVM;对于大型、重要功能区的脑AVM,血管内栓塞联合手术或放疗可提高治愈率,降低致残率和死亡率。     

小脑动静脉畸形的栓塞治疗

报告９例小脑动静脉畸形。临床表现以蛛网膜下腔及小脑内血多见，其次为三叉神经痛和癫痫，供血动脉主要是小脑上及小脑后下动脉，血管畸形直径在５ｃｍ内。本组均经动脉途径行超选择性栓塞，治疗效果良好。文中小脑动静脉畸形的特点和栓塞术操作要点进行了讨论。     

颅内动静脉畸形的栓塞治疗

颅内动静脉畸形（AVM）的栓塞治疗是现代微侵袭神经外科对该病综合治疗的重要手段之一。我院近期对１０例AVM病人实施了栓塞治疗,总结如下：１对象与方法１．１一般资料本组男８例,女２例。年龄１６～４８岁。首发症状头痛６例,癫痫发作３例,外伤后局部血管异常搏动１例。２例急起发病,８例缓慢起病。病程４d～２０年。病灶部位幕上９例,幕下１例。１．２影像学资料全部病例行CT检查。其中２例示颅内血肿,１例示蛛网膜下腔出血,３例示颅内占位,４例无异常。行MRI检查者６例,其中４例示AVM,２例示颅内占位;行MRA检查者２…     

脊髓动静脉畸形血管内栓塞治疗

目的：经血管内栓塞治疗脊髓动静脉畸形（ＡＶＭｓ）。方法：本组１８例脊髓ＡＶＭｓ，１４例采用干燥硬脑膜粒栓塞，２例采用α－氰基丙烯酸正丁酯（ＮＢＣＡ）胶粘合剂经微导管超选择性栓塞，另２例用３个０真丝线段栓塞。结果：病灶完全栓塞１５例，栓塞８０％～９０％３例。肢体瘫痪症状明显改善１６例，其中２例有手术切除史者症状未改善，平均随访３２个月，有１４例症状完全恢复正常，２例多支供血者经再次栓塞治疗后症状改善，另２例无变化。结论：血管内治疗脊髓ＡＶＭｓ优于手术治疗，应首先采用此法     

直视下栓塞联合手术切除治疗大型脑动静脉畸形

对病变广泛、位置深在或重要功能区的脑动静脉畸形(AVM),手术切除难度较大者,应用人工栓塞治疗取得了一定效果。然而这类AVM单纯经股动脉导管栓塞仅能使畸形血管的20_0~0被栓塞,开颅直视下栓塞可以提高畸形血管的栓塞率。我院自1985年12月至1991年2月应用TH胶(氰丙烯酸混合脂)行开颅直视下栓塞联合手术切除治疗大型AVM7例,获得满意效果。现报告如下:     

微弹簧圈栓塞治疗脑动静脉畸形

自１９９２年１２月至１９９３年８月，我们采用国产微弹簧圈与其它栓塞材料联合使用，栓塞治疗脑动静畸形５６例，５６例中有７例完全闭塞；栓塞范围占７０％－９５％者３４例，栓塞范围５０％－７０％者１２例，有３例栓塞范围３０％－５０％，占本组病例的５％。这种微弹簧围的优点是：（１）在荧屏上清晰可见，避免了线段栓塞的盲目性；（２）表面粗糙，易诱发血栓形成；（３）比重大，易停留在ＡＶＭ畸形病灶内，不易被血流冲走     

脑动静脉畸形手术治疗与血管内栓塞治疗

目的通过对81例脑动静脉畸形(AVM)患者分别进行直接手术切除和血管内栓塞治疗的总结,探讨AVM治疗手段的可行性和有效性。方法(1)直接手术23例,均为AVM合并脑内血肿而行急诊开颅血肿清除术 AVM切除术。(2)58例行血管内超选择栓塞术(NBCA胶),栓塞前行二维或三维DSA检查。结果直接手术组,术后复查头部MRI或DSA示病灶全切除12例,部分切除6例并在术后联合血管内栓塞达到痊愈,治愈率52.2%,病残率26.1%,死亡率21.7%。血管内栓塞组,以最后一期栓塞后的DSA资料统计栓塞程度,有49例达到完全栓塞,8例畸形血管团减少50%以上,1例减少50%以下。结论对脑AVM破裂出血且危及生命的应行急诊开颅血肿清除术并尽可能切除畸形血管团。小型AVM、单支供血AVM或Spetzler-Martin分级Ⅲ级以下的病例,追求一期完全栓塞是有可能的;Ⅲ级以上的脑AVM,采用分次、分期血管内栓塞可减少并发症和明显改善症状。因此,治疗脑AVM手段的选择应根据患者的具体情况而定。     

Stereotactic radiosurgery for intramedullary spinal arteriovenous malformations

Spinal cord arteriovenous malformations (AVM) are rare lesions associated with recurrent hemorrhage and progressive ischemia. Occasionally a favorable location, size or vascular anatomy may allow management with endovascular embolization and/or microsurgical resection. For most, however, there is no good treatment option. Between 1997 and 2014, we treated 37 patients (19 females, 18 males, median age 30 years) at our institution diagnosed with intramedullary spinal cord AVM (19 cervical, 12 thoracic, and six conus medullaris) with CyberKnife (Accuray, Sunnyvale, CA, USA) stereotactic radiosurgery. A history of hemorrhage was present in 50% of patients. The mean AVM volume of 2.3 cc was treated with a mean marginal dose of 20.5 Gy in a median of two sessions. Clinical and MRI follow-up were carried out annually, and spinal angiography was repeated at 3 years. We report an overall obliteration rate of 19% without any post-treatment hemorrhagic events. In those AVM that did not undergo obliteration, significant volume reduction was noted at 3 years. Although the treatment paradigm for spinal cord AVM continues to evolve, radiosurgical treatment is capable of safely obliterating or significantly shrinking most intramedullary spinal cord AVM.     

颅内动-静脉畸形的外科治疗评价

颅内动-静脉畸形的治疗目的是消除颅内出血风险,最大限度地保护神经功能。治疗方法包括显微外科手术、血管内栓塞治疗和立体定向放射外科治疗。本文主要讨论颅内动静脉畸形的各种治疗方法,评价其优劣,以利于制定合理的治疗策略,提高治愈率并最大限度地降低并发症的发生。     

脊髓动静脉畸形的显微外科治疗

作者5年内共行脊髓动静脉畸形显微外科切除术35例。本文总结本组病人的临床表现,讨论本病的分型和显微外科切除技术。由于本病缺乏独特的症状和体征,易误诊为其它脊柱脊髓疾病。诊断上最主要的方法是MRI和选择性脊髓血管造影,一般说来,硬脊膜和脊髓表面动静脉瘘可成功地完全切除,但团块型AVM的治疗却是一个复杂的外科问题。显微外科切除术的关键是良好显露,彻底止血和尽可能多处理供血动脉。     

胼胝体动静脉畸形的显微外科治疗

报告26例胼胝体AVM（其中1例多发）的27个病灶。5个位于膝部,4个位于体部.18个位于压部。供血动脉主要来自大脑前动脉的胼周动脉;其次是大脑后动脉的脉络膜后动脉等分支。24个AVM采用显微外科手术作了全部切除。术后能正常生活者达88.5％,无死亡,并对胼胝体AVM显微外科切除手术的体会进行了讨论。     

脑动静脉畸形的伽玛刀治疗

目的评估伽玛刀(γ-刀)对脑动静脉畸形(AVM)的治疗效果及影响因素。方法抽取72例上海伽玛刀医院于1994～1995年应用γ-刀治疗的AVM病例,回顾性分析其疗效和影响因素,探讨治疗适应证,周边剂量等。结果本组AVM直径<3cm45例,3～6cm27例;平均周边剂量20.6Gy。其中51例行血管造影等影像学随访,AVM完全闭塞率为56.9%;体积<10ml,周边剂量大于20Gy组完全闭塞率较高。头痛、癫痫的缓解率达81.8%。6例于γ-刀治疗后发生自发性脑出血。γ-刀治疗后的AVM闭塞情况和并发症的发生与病灶体积、治疗周边剂量、随访时间等因素有关。结论γ-刀是治疗脑AVM的一种较安全、较有效的治疗方法。体积<10ml,位于功能区或部位深在的AVM是适合γ-刀治疗的病例,周边剂量以20～25Gy为宜。     

Cerebral arteriovenous malformations in children: report on 62 cases

A series of 62 children with cerebral arteriovenous malformations admitted to our department in the course of 17 years (1975–1992) was reviewed in a retrospective study. In 54 cases hemorrhagic stroke was the first presenting symptom, followed by epilepsy in five cases. On admission 26 children presented with a neurological deficit, and 21 were admitted with a grade 3 status according to Botterell. Fifty-one malformations were supratentorial (41 hemispheric, 10 deep-seated) while 11 were infratentorial. According to Mori's criteria, 28 lesions were small, 19 medium, and 15 large. Fifty-two children were operated on, with total excision of the malformation achieved in 47 cases. In two children the malformation recurred. The evolution of neurological disorders has been studied with a mean follow-up of 8.5 years. Fifty patients had a satisfactory outcome on the Glasgow Outcome Scale. Four children died. These results were compared with those reported elsewhere in the pediatric literature.     

A three-dimensional color-printed system allowing complete modeling of arteriovenous malformations for surgical simulations

To develope a colored realistic AVM model using three-dimensional (3D) printing for surgical planning and research. Raw computed tomography angiography (CTA) and magnetic resonance venography (MRV) data were integrated and used for reconstruction. Each AVM model included the nidus, the feeding arteries, the draining veins, the sinuses, the adjacent principal arteries, and the skull. The models were employed to plan surgical and endovascular treatments. Surgical feedback was obtained using a survey. Five AVM cases were included. The AVMs and the models thereof did not differ significantly in terms of length, width, or height, as measured via magnetic resonance imaging (all p > 0.05). The 3D AVM models were thus accurate. The overall score on the questionnaire survey was >4 point; the model thus aided the planning of interventional surgery. All surgeons were confident that the 3D models reflected the true lesional boundaries. Our 3D-printed intracranial AVM models were accurate, and can be used for preoperative planning and training of residents. The models improved surgeons’ understanding of AVM structure, reducing operative time.     

Cerebral arteriovenous malformations in children

Over the past 10 years (1982–1992), we have been actively involved in the management of 179 cerebral arteriovenous malformations (CAVMs) in children and infants. Seventy-seven were true vein of Galen malformations (VGAMs) and 102 were pial AVMs (PAVMs), i.e., developed in the subpial space. Hemorrhage occurred as the first symptom in 50% of the children with pial AVMs, but was present in none of the VGAM cases. Only 31 children were found to be unsuitable for endovascular treatment, and in 124 cases embolization was indicated as the primary treatment (104 embolization performed). Only 21 children underwent a direct surgical approach (none in the VGAM group). In the embolized group in whom treatment has been completed (n = 56), 8 children died, 39 have an anatomical cure, and 34 are clinically normal. In the group under treatment (n = 56), 16 are not normal. The problems are timing and the aims (total or partial treatment) of the therapeutic procedures. In the nonembolized group (n = 31), 8/13 of the pial lesions were operated on (no mortality, 2 patients with moderate neurological deficits). In the VGAM group 13/18 died and 4 had spontaneous thrombosis (only 1 is neurologically normal). In the nonembolized group 13 lesions have been completely excluded, but only 5 patients are neurologically normal. This fact again stresses the need for prognostic evaluation before treatment and a clear definition of the treatment aims. Analysis of a large number of published series on the management of children with AVMs (1017 cases) reveals inconsistencies that hamper proper evaluation and comparison. In our experience, endovascular treatment always seems to be the best primary treatment in both VGAMs and PAVMs. However, management of children with these lesions requires a large multidisciplinary team, which is the only way of offering the most suitable and effective treatment, the sole guarantee of a good result.     

颅内巨大动静脉畸形的治疗及其并发症防治

目的探讨颅内巨大动静脉畸形(arteriovenous malforation,AVM)的治疗及其防治并发症的有效方法。方法回顾性分析2011.4~2014.4以手术切除为主,联合栓塞及伽玛刀治疗的18例巨大AVM患者的临床资料。结果无死亡病例,有2例术前昏迷的患者,术后昏迷程度减轻。格拉斯哥预后(GOS),5分12例,4分3例,3分1例,2分2例。结论根据患者的临床资料,制定个体化的治疗方案,重视细节,采用手术切除联合术前栓塞或/和术后放疗可以有效地降低颅内巨大AVM的手术并发症。     

高颈髓髓内肿瘤术后呼吸循环障碍与处理

目的：探索呼吸功能丧失的高颈髓髓内肿瘤手术后呼吸功能能否恢复及其它并发症。方法：对一例已丧失自主呼吸的Ｃ１～Ｃ４室管膜瘤，术中、术后进行２４天的呼吸、血压、心电等持续监护。结果：（１）术后１～３天，自主呼吸有明显的恢复，尤其在大剂量使用甲基强的松龙后。术后４～９天自主呼吸不平稳，次数减少：术后１０～２１天，呼吸有较好的恢复，但不能维持正常的血气水平，并出现肺感染，呼吸功能再次丧失。（２）术后６小时出现低血压，一直未恢复，依靠多巴胺维持。（３）术后还出现高热，腹胀，低血钠，高尿钠，肺感染等并发症。结论：高颈髓髓内肿瘤一旦出现呼吸功能改变，表明病情已很严重，应立即手术治疗。手术后呼吸可以有一定程度的恢复。早期大量使用糖皮质激素，可以减轻脊髓的继发性损伤。为了减少自主呼吸通气效果较差带来的低氧和高二氧化碳血症造成脊髓的继发性损害，术中、术后应该严格进行呼吸机辅助通气，保持二氧化碳分压小于５．３３ｋＰａ（４０ｍｍＨｇ），术后严重的呼吸功能障碍的治疗有待于进一步研究。