脳動静脈奇形，瘻手術における穿通枝フィーダーの“解剖と神経機能の可視化”による機能温存

抄録

Background: Surgical resection of an arteriovenous malformation (AVM) or fistula (AVF) is often complicated by severe bleeding that is difficult to manage. In order to perform resection successfully, surgical strategy is based on detailed understanding of the anatomy of not only feeders and drainers, but also small perforators; this information is difficult to obtain before surgery. Moreover, in deeper locations, an AVM is often close to important areas such as the pyramidal and optic tracts, and it is important to preserve their functions. In this study, we describe our strategies to overcome these problems, and report our results using illustrative cases.
Methods: From 2006 to 2015, 61 consecutive patients with AVM or AVF underwent surgery at our institution. In order to improve the outcomes of resection and preserve function in all cases, deep perforators were visualized using preoperative three-dimensional (3D) fusion images, and functions were visualized using evoked potentials.
Results: In 6 of 61 cases, evoked potentials decreased during surgery. In 4 cases, decreased motor evoked potentials were associated with transient hemiparesis. One patient developed permanent worsening of hemianopsia. We report 2 illustrative cases of AVM, in which preoperative 3D images were useful in identifying deep small feeders and anatomical relationships between the AVM and surrounding structures, enabling preservation of function.
Conclusions: In the surgical management of a complex AVM or AVF, precise visualization of complex feeders, nidus structures, drainers, and perforating vessels, as well as associated neural functions, using preoperative 3D images and intraoperative evoked potentials, could be useful in functional preservation.