显微手术切除儿童深部脑动静脉畸形  

Microsurgery for deep cerebralarteriovenous malformations in thalamus,basal ganglia and insula in children

作　　者：曾翰海 石武杰 章培良 翁建斌 林超[1] 王宁[1] 沈志鹏[1] Zeng Hanhai;Shi Wujie;Zhang Peiliang;Weng Jianbin;Lin Chao;Wang Ning;Shen Zhipeng(Department of Neurological Surgery,Affiliated Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Child Health,Hangzhou 310003,China)

机构地区：[1]浙江大学医学院附属儿童医院神经外科,国家儿童健康与疾病临床医学研究中心,杭州310003

出　　处：《中华小儿外科杂志》2019年第12期1097-1101,共5页Chinese Journal of Pediatric Surgery

摘　　要：目的探讨儿童深部(丘脑、基底节、岛叶)脑动静脉畸形(arteriovenous malformations,AVMs)的显微手术治疗经验。方法回顾性分析2015年6月至2018年6月收治的10例行显微手术治疗的深部脑AVMs的临床资料。10例中,男8例,女2例;平均年龄为7.8岁。AVMs位于岛叶4例,丘脑3例,基底节3例;直径小于3 cm者8例;畸形血管破裂9例;病灶局限8例。Spetzler-Martin分级Ⅲ级6例,补充分级Ⅳ级以下10例,均行显微手术治疗。通过术后复查DSA及不同时间节点mRS评分探讨手术效果。结果10例患儿中经脑皮质入路8例,经外侧裂入路1例,经胼胝体入路1例。其中,畸形血管团术中完整切除8例;Spetzler-Martin分级Ⅳ级1例行急诊显微手术切除;行急诊脑室外引流术1例,二期再行显微手术治疗。术后偏瘫4例,包含1例术前Spetzler-Martin分级Ⅳ级者,经康复训练均有不同程度好转。临床随访6个月至3年,无复发及再次出血,预后良好者6例。随访终点mRS评分3分以下者(6例)较术前(5例)及出院(5例)时多。结论儿童深部脑AVMs出血风险高。对于有病损小、畸形局限等特点的特选病例,显微手术切除是治疗上可供选择的治疗方式,具有全切率高、再出血率低等特点,但手术难度大、要求高,需要有相当经验的神经外科医生进行手术。Objective To summarize the experiences of microsurgical removal of deep cerebral arteriovenous malformations(AVMs)in thalamus,basal ganglia and insula in children.Methods A retrospective analysis was conducted for 10 cases of deep cerebral AVMs undergoing microsurgery from June 2015 to June 2018.There were 8 boys and 2 girls with an average age of 7.8 years.The lesions were located in insular lobe(n=4),thalamus(n=3)and basal ganglia(n=3).Eight lesions were<3 cm in diameter,9 lesions ruptured,8 lesions were localized,Spetzler-Martin grade III and supplementary grade below IV accounted for 6 and 10 respectively.The outcomes were evaluated by postoperative digital subtraction angiography(DSA)and modified Rankin Scale(mRS)scores at different timepoints.Results The operative approaches were trans-cortical(n=8),lateral fissure(n=1)and corpus callosum(n=1).Among 8 cases of total resection,1 case of Spetzler-Martin IV underwent emergency microsurgery while another case had emergency ventricular drainage plus second-stage microsurgical lesion removal.Among 4 cases of hemiplegia,one child of Spetzler-Martin IV had a remission after postoperative rehabilitation training.During a follow-up period of 6 months to 3 years,there was no onset of recurrence or rebleeding and 6 of them achieved an excellent outcome.Children scoring<3 via mRS during follow-ups(n=6)were more than preoperation(n=5)and after discharge(n=5).Conclusions Children with deep cerebral AVMs has a high risk of bleeding.For selected small and localized lesions,microsurgical resection offers the advantages of high total resection rate and low rebleeding rate.However,due to high operative difficulties,experienced neurosurgeons are recommended.

关 键 词：颅内动静脉畸形 显微外科手术 儿童 

分 类 号：R74[医药卫生—神经病学与精神病学]