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本症例は右側頭頭頂後頭葉を占拠する巨大脳動静脈奇形で,著しい慢性脳虚血を伴い,頻回の痙攣発作と痴呆などの進行性神経脱落症候を呈した.全摘出はきわめて危険かつ困難であり,さらにCTにて大脳皮質下に広範な石灰化を認め,症状改善も困難と考えられていた.新開発のガイドワイヤーにより超選択的カテーテル挿入が可能となり,術前staged embolizationと術中embolizationの併用によりnor...mal perfusion pressure breakthroughの合併なく全摘出術に成功した.さらに術前embolizationの過程で,shunt flowの軽減に伴い神経脱落症候が劇的に改善したことも注目に値する.
The authors describe a huge arteriovenous malformation (AVM) in the right temporo-parieto-occipital lobes that was successfully removed after a multi-staged embolization of the feeding arteries. The patient, a 54-year-old housewife, had presented uncontrolable epilepsy, progressive dementia, hemianopsia, hemiparesis, and hemisensory impairment of the left side. Angiography revealed a huge AVM mainly being nourished by the following sources : the parieto-occipital arteries of the posterior cerebra] artery, the temporal branches of the middle cerebral artery and dura] branches from the external carotid and vertebral arteries. Further, the cortical draining veins over the entire hemisphere were markedly, dilated, and the superior sagittal and straight sinuses visualized poorly, probably due to the congestion in the venous circulation caused by the arteriovenous shunt. CT scans also revealed multiple, club-like calcification in the parietal and frontal subcortical regions, indicating chronic brain ischemia caused by the remarkable arterial s_teal and/or venous hypertension. . Preoperative super-selective embolization was done in four sessions, using newly developed, low-friction, high -torque guide wires. and this resulted in a dramatic neurological improvement, especially with regard to the dementia. Then, following intraoperative embolization of the remaining feeding arteries, the AVM was success-fully removed. The patient tolerated these procedures well without hemodynamic complications, and after a few months of rehabilitation, she resumed her normal life.続きを見る
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