颅内血管性病变的磁共振时间飞跃法血流成像

报告了３０例颅内血管性病变的磁共振时间飞跃法（ＴＯＦ）血流成像资料，包括动脉瘤８例、动静脉畸形１３例和血管闭塞９例。其中２１例作了与ＤＳＡ的对照。结果发现，ＴＯＦ血流成像方法无创伤、危险小、检查时间短，对颅底动脉环和动脉瘤显示较好，可显示动静脉畸形（ＡＶＭ）的供血动脉和引流静脉，大血管的闭塞诊断准确。缺点是图像欠清晰、伪迹较多。三维成像分辨力高、图像对比好，但对慢血流不敏感。笔者认为ＭＲＴＯＦ血流成像具有明显的临床实用价值。     

Endoscopic procedures for resection of arteriovenous malformations

BACKGROUND

Resection of arteriovenous malformations (AVMs), particularly those located in functional areas, requires precision. To enhance that precision, endoscope-assisted microsurgery has been employed at Loma Linda University.

METHODS

Twenty-five consecutive cases of AVM were treated microsurgically with endoscopic assistance. Patients were divided into two groups: (1) those having AVMs in functional areas, and (2) those whose AVMs extended into the ventricle, either in the trigonal area or the capsulocaudatothalamic area. The endoscope was inserted into the subarachnoid space to interrupt communicating venules around the major draining vein and into the cleavage developed between the AVM venous loops and surrounding brain tissue as shunting arterioles and communicating venules were interrupted. For surgery of intraventricular AVMs, the curved endoscope was inserted into the ventricle, providing visualization of the AVM core, which was dissected from the ventricular side.

RESULTS

AVMs were totally resected in all cases except for two patients with capsulocaudatothalamic AVMs, which were decreased in size sufficiently to receive radiosurgery.

CONCLUSION

Endoscope-assisted microsurgery enhances magnification, illumination, and technical precision while the surgeon is dissecting the AVM core vessels and while operating on AVMs extending into the ventricle.     

Syringobulbia Caused by Delayed Postoperative Tethering of the Cervical Spinal Cord – Delayed Complication of Foramen Magnum Decompression for Chiari Malformation

Summary  Postoperative tethering of the high cervical spinal cord is a rare cause of neurological deterioration after foramen magnum decompression (FMD) with duraplasty for Chiari type I malformation. A review of the literature revealed that only 5 cases have been reported. This entity is not widely known to occur as a complication of the common surgical procedure for Chiari type I malformation. A 17-year-old boy experienced rapidly progressive neurological deterioration over a 3-month period. FMD and duraplasty with lyophilized cadaver dura had been performed 8 years previously. Follow-up MR images showed that the cerebrospinal fluid (CSF) space dorsal to the cord was gradually disappearing and that syringobulbia had developed. Opening the dura mater of the posterior fossa revealed dense fibrous scarring, arachnoid thickening over the cervicomedullary area, and tethering the cord to the dura from the medulla to C2. The adhesions were dissected free, and the tethering was released. A syringosubarachnoid (SS) shunt was inserted and duraplasty was performed with an expended polytetrafluoroethylene sheet (Gore-Tex). Postoperative MR images demonstrated that the syringobulbia had completely collapsed and that a dorsal CSF space was present. Follow-up MR images provided significant information on the cervical spinal cord tethering after FMD with duraplasty for Chiari malformation. We encourage sharp surgical detethering and duraplasty with Gore-Tex to avoid retethering. Early recognition and treatment of this unusual but important complication are emphasized.     

脊髓血管畸形的MRI诊断(附3例报告及文献复习)

目的：评价ＭＲ成像对脊髓血管畸形的诊断价值。方法：共３例，其中２例为硬脊膜动静脉瘘，１例为根脊膜血管畸形，在１．５Ｔ磁共振机上应用表面线圈作高分辨ＭＲ成像，其结果与选择性脊髓动脉造影进行对照。结果：ＭＲ不仅可显示畸形血管特征性的快速流空现象，而且还可显示畸形血管远端髓内长Ｔ１、长Ｔ２信号改变。ＭＲＩ与血管造影结果基本符合。结论：ＭＲ成像是评价脊髓血管畸形十分敏感和有效的方法     

44例Arnold－Chiari Ⅰ型畸形的MRI分析

目的：分析ＭＲＩ对Ａｒｎｏｌｄ－Ｃｈｉａｒｉ畸形的诊断价值及枕大孔前后径、小脑扁桃体垂直径同该病的关系。材料与方法：回顾性分析４４例ＣｈｉａｒｉⅠ型畸形的ＭＲＩ表现。选择４４例经ＭＲＩ证实的正常病例作为对照组，测量所有病例的枕大孔前后径及小脑扁桃体垂直径，采用ｔ检验进行统计学分析。结果：本组中８２％（３６／４４）有不同程度的脊髓空洞症，７７％（３４／４４）有延髓的拉长疝出，２５％（１１／４４）合并骨质发育异常。两组之间枕大孔前后径无显著性差异（Ｐ＞０．０５），小脑扁桃体垂直径有高度显著性差异（Ｐ＜０．００１）。结论：ＭＲＩ是Ａｒｎｏｌｄ－Ｃｈｉａｒｉ畸形及其合并症的最佳诊断方法，小脑扁桃体垂直径增大对诊断有重要价值。     

手术治疗小儿先天性动静脉瘘的疗效观察

目的探讨小儿先天性动静脉瘘的手术治疗效果。方法本组共收治先天性动静脉瘘惠儿5例,均行动脉造影及多普勒超声检查,发现局限型2例,弥漫型3例,病变均发生于四肢。对5例惠儿行手术治疗,局限型行病灶切除,弥漫型扩大切除病变组织,缺损区域以游离皮瓣移植修复。结果5例患儿随访1～3年。2例局限型患儿中1例治愈,1例病情得到控制;3例弥漫型病变中,2例病情得到控制,1例病情持续进展且因并发症已行左上肢截肢手术。结论手术治疗可作为cAvF局限型的首选治疗方式,而弥漫型单纯采取手术治疗则具有较高的复发几率。尽管如此,小儿CAVF还应尽早治疗以防止肢体畸形及循环系统衰竭等严重并发症的发生。     

CAVM栓塞剂NBCA混悬液配比浓度的基础和临床研究

目的：定量分析动静脉畸形（AVM）栓塞到α－氰基丙烯酸丁酯（NBCA）混悬液配比与动静脉（A－V）循环时间之间的关系，探讨临床应用微导管栓塞脑AVM（CAVM）所需的最佳NBCA混悬液配比浓度。方法：（1）16例颅内出血患者的离体新鲜动脉血和浓度分别为20％，33％，50％，70％和80％的NBCA混合，测定不同浓度NBCA在离体新鲜动脉血中的凝固时间；（2）对1例AVM和1例AVF的5支供血动脉行超选择性栓塞治疗。结果：（1）不同浓度NBCA与离体新鲜动脉血凝固时间之间存在着指数函数关系，T（凝）＝e^1.9994-4.187D;(2)AVM栓塞术后畸开血管团闭塞约90％，AVF栓塞术后瘘口基本被封闭。结论：A－V循环时间与NBCA配比浓度之间存在指数函数关系，为临床运用微导管栓塞CAVM提供了一定的理论依据。     

Arnold-Chiari畸形的MRI诊断

目的探讨Arnold-Chiari畸形(ACM)MRI表现。方法25例ACM均经MRI诊断,并经手术及临床证实。结果小脑扁桃体疝至枕大孔平面下5～20mm21例,3～4mm4例,23例扁桃体下极变尖与扁桃体前池变形,其中扁桃体前池消失和或颈髓扭曲成角10例,伴脊髓空洞21例,脑积水5例。结论小脑扁桃体位于枕大孔下>5mm即可诊断ACM,对<5mm者,在诊断ACM前需注意正常扁桃体暂时低位,并需结合临床症状体征。     

颌面部动静脉畸形的临床分型与治疗

目的探讨颌面部动静脉畸形(arteriovenous malformation,AVM)的临床分型与治疗方法。方法106例颌面部AVM患者根据病变表现特点分为四种类型,其中囊状扩张型38例,局限增厚型22例,弥漫增厚型42例,颌骨中心型4例。106例患者分别采用手术治疗8例(Ⅰ组),单纯供血动脉栓塞23例(Ⅱ组),供血动脉栓塞加瘤内硬化剂注射37例(Ⅲ组),供血动脉栓塞加瘤体切除38例(Ⅳ组)。结果全组病例随访1-11年,Ⅰ、Ⅱ、Ⅲ、Ⅳ组的治愈率分别为62．50％、17．39％、89．19％、97．37％。1例患者栓塞治疗时并发脑异位栓塞死亡。结论新的临床分型有利于治疗方法的选择。优良的数字减影血管造影是颌面部AVM必不可少的决定性检查。单纯供血动脉栓塞仅能治愈单支终末供血的局限性病变,而多支动脉供血的病变单纯栓塞后容易复发。供血动脉栓塞加瘤内硬化剂注射或供血动脉栓塞加病变切除是颌面部AVM的有效治疗方法。     

Late spinal dislocation after treatment of spinal arteriovenous malformation. A case of Charcot spinal arthropathy

Neuropathic arthropathy of the spine is a destructive condition of the spine which is secondary to a loss of the protective proprioceptive reflexes. In the majority of cases, it occurs in patients who have suffered from traumatic medullary lesions and is responsible for destruction of the vertebral bodies and considerable spinal deformity. We report a case of neurogenic lumbar arthropathy in a patient with a spinal arteriovenous malformation. This vascular lesion caused considerable disturbances of proprioception. The course was favorable with regard to the deformity after correction and fusion by posterior approach.