作者感谢所有的临床团队每天对 UCSD 的 AVM 患者的护理。

根据机构指南获得知情同意后, 以下所述的所有程序均作为脑车辆患者的护理标准执行. 
 1. 初始患者评估和成像 注意: 破裂车辆的患者通常在畸形被发现后出现在头痛或癫痫检查的影像上。车辆破裂的患者经常出现头痛、恶心、呕吐、虚弱、麻木和/或视力变化的急性发作. 
<ol> <li> 通过访问患者和/或家庭 (以确定以前的破裂状态、家族病史) 和执行详细的神经系统检查来获取完整的历史记录, 评估意识和方位、颅神经功能、下肢运动和感官功能, 和反射。这项检查可能会发现神经系统的缺陷, 由于隐性血管窃取, 局部质量效应, 和/或视觉变化 (与枕车辆)。在发生 AVM 破裂的情况下, 请将病人交给重症监护病房 (ICU), 并根据美国心脏协会 (阿哈)/美国中风协会 (ASA) 的指导方针与 neurocritical 护理小组一起。 9 </li> <li> 获得了平头计算机断层扫描 (CT) 每机构的协议, 以评估急性出血, 即, 一个地区的异常颅内 hyperdensity, 往往有质量效应。通过 CT 或磁共振 (MR)-血管造影, 以确定脑血管和任何潜在的血管异常的机构的协议。 10 对神经外科和放射科团队的所有图像进行解释. </li>
	<li> 如果患者神经稳定, 获得知情同意, 并通过六导管血管造影和 #177 对患者进行明确的血管成像; 栓塞 (见下文2和3节)。如果病人有渐进性的神经下降从出血, 放置颅内压监测和/或启动渗透疗法按照阿哈/ASA 准则 9 。进行血肿排空和 #177; AVM 切除术 (见下面4节) 在诊断六导管血管造影前或紧接后. </li>
</ol> 2。六血管造影 <ol> <li> 在麻醉组的帮助下, 如果稳定的话, 或全身麻醉下的病人仰卧在透视表上的位置 (典型的插管诱导与芬太尼 [5-10 心动/公斤], 咪达唑仑 [0.2-0.4 毫克/千克], 和0.5 毫克/千克罗库, 其次是麻醉维护与异丙酚在 50-150 心动/千克/分钟和瑞芬太尼在 0.1-0.5 心动/千克/分)。 11 </li> <li> 使用穿刺腹股沟访问套件和修改后的 Seldinger 技术来放置右股动脉鞘. 12 <ol> <li> 清洁 (含2% 氯己定的葡萄糖酸和70% 异丙醇) 和 sterilely 褶皱腹股沟. </li>
		<li> 触在腹股沟折痕处股动脉。注射1-2 毫升的1% 利多卡因 HCl 作为局部麻醉进入表面皮下组织。将微针插入股动脉腔内, 针在 45 #176; 角度对皮肤. </li>
		<li> 通过微针推进微丝, 取出微针保持微丝到位。做一个0.5cm 皮肤穿刺与11刀片在现场 microwire 退出皮肤. </li>
		<li> 插入容器扩张, 然后将该容器的微线和内部部分扩张, 使该容器的外部部分保持扩张. </li>
		<li> 在容器扩张的流明处插入一根 j 线, 并取出扩张, 保持 j 线到位. </li>
		<li> 在 J 线上插入一个5或 6-法国鞘到股动脉。取出 J 线, 保持鞘在动脉中的位置. </li>
	</ol> </li> <li> 将0.035 丝和 4-法国诊断导管头下单或双透视 (每秒3-5 帧) 提升主动脉, 并通过注射5-8 毫升不透明的造影剂来选择性 catheterize 和图像 (240毫克/毫升) 右侧颈内动脉、右椎动脉、左颈内动脉、左颈外动脉和左椎动脉. </li>
	<li> 复查记录的血管造影图象, 以确定该 AVM 的喂养血管和引流静脉. </li>
	<li> 如果不进行急性栓塞, 请卸下诊断导管和丝, 并按照制造商的说明, 用密封剂装置来固定股动脉, 13 或按住压力至少10分钟. </li>
</ol> 3。avm 栓塞 注意: 如果 avm 可以接受血管内和随后的外科治疗 (按照确定的评分标准, 1 , 8 以及外科医生和多学科会议评价), 最初的栓塞可能是在延迟的方式或与诊断血管造影的同一时段进行的。栓塞经常上演, 以减少破裂和中风的风险, 从迅速改变的流动动力学. 
<ol> <li> 获取知情同意。以协助从麻醉地方患者在一般麻醉之下和在 2.1, 并且安置患者仰卧在透视桌 (如果不同时作为最初的血管造影). </li>
	<li> 与神经监测组一起, 通过体感诱发电位 (SSEPs)、经颅运动诱发电位 (TcMEPs)、视觉诱发电位 (vep)、听觉脑干反应 (abr) 和/或脑电图 (eeg)。继续在整个案件的神经监测, 以跟踪 real-time 的功能, 关键的神经通路。SSEPs, TcMEPs 和脑电图作为标准的神经监测协议的一部分, 与 abr 椎/基底动脉病变, 和 vep 的视觉皮层病变。 14 </li> <li> 使用改进的 Seldinger 技术获取股动脉通路, 并在2.2 中插入 6-法国股骨鞘. </li>
	<li> 引入一个预轴系统, 由一个 6-法国导管 (一个更大的孔导管在系统的外面为稳定), 4 法国诊断导管 (一个更小的孔导管安置在6法国指南之内为选择性导管插管), 和一个0.035 丝 (定位在4法国诊断导管的腔内的系统指导) 作为一个单位进入股骨鞘. </li>
	<li> 如在2.3 前进, 轴系统头和有选择地 catheterize 大口径的颈血管 (即左或右内颈动脉或脊椎), 所期望的喂养 AVM 血管来源于诊断导管和将导导管推进至适当的宫颈段以支持。移除诊断导管, 通过小注射造影剂的快速分散来确保足够的血管径流, 并通过注射不透明造影 (5-8 毫升 240) 进行诊断血管造影 (在单声道或双透视下, 每秒3-5 帧)。毫克/毫升) 和 #160; 评估 AVM 的血液供应。叠加制导图像 (期望叠加船只运行与 real-time 透视) 或路线图图像 (船舶减法模板), 然后创建, 以协助微导管的目标 AVM 血管. </li>
	<li> 在腹股沟的导管中引入二甲基亚砜相容导管和 microwire, 并推进头选择性地 catheterize 所需的喂养动脉, 使用叠加或路标引导. </li>
	<li> 一旦栓塞的位置达到与导管它是冲洗与 (亚甲基亚砜)。一旦冲洗, 栓塞的 AVM 病灶和理想的喂养动脉通过控制注射的无线电不透明液体栓塞剂下的负面路线图图像, 直到达到回流耐受。总体积的 embolisate 使用的是由大小的病变, 渗透的病灶, 并允许回流。注意避免 embolisate 回流到非 AVM 动脉, 或远端栓塞到引流静脉。一旦栓塞完成, 背部吸入的栓塞注射器举行和导管被删除下透视可视化. </li>
	<li> 根据需要重复栓塞其他喂养血管, 目标至少50% 术前尼达尔栓塞。 15 一般情况下, 只有一个或两个喂食容器和和 #60; 40% 的病灶是栓塞在一个单一的程序, 使分期栓塞常见. </li>
	<li> 在步骤3.5 中通过引导导管通过造影剂注入最终血管造影, 以评估 AVM 栓塞并确保母血管通畅. </li>
	<li> 在步骤2.5 中取出导导管并闭合股动脉。如果病人被直接送往或切除, 股骨鞘可以留在术血管造影 (在步骤4.8 中描述). </li>
</ol> 4。avm 切除术 <ol> <li> 获得知情同意, 在麻醉的协助下, 将患者置于全身麻醉下, 如步骤2.1 所示, 并根据 avm 的位置和所需的开颅手术定位病人。获得血液同意和产品. </li>
	<li> 与 neuromonitoring 团队一起, 按照3.2 中的说明建立基线 neuromonitoring, 并在整个案例中继续进行监视. </li>
	<li> 同步术前成像与术神经导航系统使用表面匹配, 标记, 或指针注册, 根据导航系统的规范. </li>
	<li> 如果鞘尚未到位, 则在步骤2.2 中获得腹股沟通道. </li>
	<li> 使用高功率钻孔系统对颅骨内特定的 AVM 位置进行开颅手术, 确保大骨外露。
	<ol> <li> 使用 #15 刀片切割皮肤和盔瓣。通过在皮肤边缘上放置骨架夹和/或使用凝固设置 (烧灼医疗产品, 清水, FL), 获得止血烧灼电。如果计划的切口涉及部下的肌肉, 用电切割筋膜/肌肉。用骨膜升降梯从骨上切开软组织瓣, 使颅骨显露。另外, 周嫁接可以在这个时候单独收获, 以帮助以后关闭。钩子用于软组织缩回. #160; 冲洗并获得止血. </li>
		<li> 在所需开颅的外围创建一个或多个毛刺孔, 并使用高功率钻孔系统在 3 mm 直径的火柴钻头上进行。额外的毛刺孔将允许更短的骨切割和硬脑膜被剥离 multifocally 之前执行开颅手术. </li>
		<li> 将硬脑膜从颅骨内侧剥离, 用骨升降机或踏板附着在骨内表面, 完成开颅手术, 用锥形钻头与踏板附着的硬脑膜连接毛刺孔。保护.如果可能的话, 计划开颅手术, 以确保早期进入脑脊液 (CSF) 蓄水池排水. </li>
		<li> 另一种方法是, 在弗雷泽和 #39 或科克和 #39 点 (在创建一个小的毛刺孔, 如在 4.5.1, 用 #11 刀片切开硬脑膜) 进行脑脊液引流时, 将外部心室引流置于侧脑室。腰椎引流放置在腰椎膜囊穿刺后与大口径陶西针在大约 L3-L4 或 L4-L5 间隙也可用于脑脊液排水. </li>
	</ol> </li> <li> 取出骨瓣并通过双极电进行止血后, 将硬脑膜 tack-up 缝合以关闭硬膜外间隙, 用 C1 钻头在骨开颅周围的小孔中钻孔, 并确保硬脑膜这些部位的骨骼使用4-0 缝合线。然后, 使用 #11 或 #15 刀片打开硬脑膜。注意不要伤害皮层或皮质血管。一旦一个小 durotomy 已经创建, 打开其余裸露的硬脑膜, 无论是十字交叉或 c 形的时尚使用 Metzenbaum 剪刀, 用杰拉尔德钳, 以提高硬脑膜边缘和可视化剪刀的秘诀, 而切割保存下属皮质结构. </li>
	<li> 使用具有1.5X 至17.0X 的可变放大容量的操作显微镜和10X 目镜, 对 AVM 进行切除。 5 其他形式的手术放大倍数, 如 exoscope, 也可以使用。
	<ol> <li> 开始显微外科切除术首先解剖在蛛网膜下腔 (使用钝和尖锐技术与双极钳, 弯曲解剖, 和 microscissors) 定义 AVM 解剖和揭露它的边缘, 自由引流静脉, 并获得近端控制通过识别和解剖免费的所有喂养动脉. </li>
		<li> 非常小心地识别和保存在 avm 早期的引流静脉, 因为阻断静脉引流前的动脉馈线导致充血的 avm 和增加的破裂风险. </li>
		<li> 在定义这一解剖后, 通过在双极性钳的尖端和使用高达30瓦特的功率, 或通过在双极电之间轻轻地夹住血管, 将动脉供血动脉凝结成近远端的 AVM。放置小动脉瘤夹. </li>
		<li> 使用双极性钳 (用于解剖和电) 和可变动作吸入尖端, 在病灶周围的脑实质内立即解剖圆周。脑牵引器可用于促进深部解剖的可视化. </li>
		<li> 在完成 AVM 解剖后, 使用双极性电作为步骤4.7.3 和/或修剪任何引流静脉。从切除腔中取出 AVM。清除整个病灶以消除未来出血风险是至关重要的. </li>
		<li> 如果正在尝试 post-hemorrhage 手术切除, 则从 AVM 病灶中取出远端的血肿, 直到脑部减压, 并确定喂养血管和引流静脉。这些地标之后被识别, 继续 AVM 尼达尔切除术4.7 步. </li>
	</ol> </li> <li> 在 AVM 移除后, 执行术血管造影, 如步骤 2.1-2.4 所示, 使用在步骤4.4 中放置的动脉鞘。使用术中或双平面血管造影或 C 臂透视, 确保完全尼达尔切除. </li>
	<li> 采用双极性电作为阶梯 4.7.4, 用可吸收止血剂轻轻排入切除腔, 获得细致止血。用4-0 缝合线关闭或 re-approximate 硬脑膜, 如果需要的话, 用围颅或人工硬脑膜移植。用电镀系统代替和固定骨瓣, 并用间断的可吸收缝合线关闭盔瓣和皮肤, 用于深层, 或者是主食或为皮肤缝合。取出腹股沟鞘, 并在2.5 步中固定腹股沟. </li>
	<li> Extubate 如果能够, 并将病人转移到 ICU 进行严密的神经监测和恢复. </li>
</ol> 5。长期随访 <ol> <li> 在学确认完整的 AVM 切除 (通过术或术后导管造影) 后, 通过导管血管造影在1和5年后的后处理中获得远程成像. </li> </ol>

<ol>
	<li>Spetzler, R. F., Martin, N. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+proposed+grading+system+for+arteriovenous+malformations.">A proposed grading system for arteriovenous malformations.</a> J Neurosurg. 65 (4), 476-483 (1986).</li><li>Stapf, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Predictors+of+hemorrhage+in+patients+with+untreated+brain+arteriovenous+malformation.">Predictors of hemorrhage in patients with untreated brain arteriovenous malformation.</a> Neurology. 66 (9), 1350-1355 (2006).</li><li>Kondziolka, D., McLaughlin, M. R., Kestle, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simple+risk+predictions+for+arteriovenous+malformation+hemorrhage.">Simple risk predictions for arteriovenous malformation hemorrhage.</a> Neurosurgery. 37 (5), 851-855 (1995).</li><li>Fukuda, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multicenter+assessment+of+morbidity+associated+with+cerebral+arteriovenous+malformation+hemorrhages.">Multicenter assessment of morbidity associated with cerebral arteriovenous malformation hemorrhages.</a> J Neurointerv Surg. , (2016).</li><li>Conger, A., Kulwin, C., Lawton, M. T., Cohen-Gadol, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endovascular+and+microsurgical+treatment+of+cerebral+arteriovenous+malformations:+Current+recommendations.">Endovascular and microsurgical treatment of cerebral arteriovenous malformations: Current recommendations.</a> Surg Neurol Int. 6, (2015).</li><li>Mohr, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Medical+management+with+or+without+interventional+therapy+for+unruptured+brain+arteriovenous+malformations+(ARUBA):+a+multicentre,+non-blinded,+randomised+trial.">Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial.</a> Lancet. 383 (9917), 614-621 (2014).</li><li>Crawford, P. M., West, C. R., Chadwick, D. W., Shaw, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Arteriovenous+malformations+of+the+brain:+natural+history+in+unoperated+patients.">Arteriovenous malformations of the brain: natural history in unoperated patients.</a> J Neurol Neurosurg Psychiatry. 49 (1), 1-10 (1986).</li><li>Lawton, M. T., Kim, H., McCulloch, C. E., Mikhak, B., Young, W. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+supplementary+grading+scale+for+selecting+patients+with+brain+arteriovenous+malformations+for+surgery.">A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery.</a> Neurosurgery. 66 (4), 702-713 (2010).</li><li>Hemphill, J. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+Management+of+Spontaneous+Intracerebral+Hemorrhage:+A+Guideline+for+Healthcare+Professionals+From+the+American+Heart+Association/American+Stroke+Association.">Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.</a> Stroke. 46 (7), 2032-2060 (2015).</li><li>Gross, B. A., Frerichs, K. U., Du, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sensitivity+of+CT+angiography,+T2-weighted+MRI,+and+magnetic+resonance+angiography+in+detecting+cerebral+arteriovenous+malformations+and+associated+aneurysms.">Sensitivity of CT angiography, T2-weighted MRI, and magnetic resonance angiography in detecting cerebral arteriovenous malformations and associated aneurysms.</a> J Clin Neurosci. 19 (8), 1093-1095 (2012).</li><li>Hashimoto, T., Young, W. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anesthesia-related+considerations+for+cerebral+arteriovenous+malformations.">Anesthesia-related considerations for cerebral arteriovenous malformations.</a> Neurosurg Focus. 11 (5), 5 (2001).</li><li>Seldinger, S. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+replacement+of+the+needle+in+percutaneous+arteriography;+a+new+technique.">Catheter replacement of the needle in percutaneous arteriography; a new technique.</a> Acta. 39 (5), 368-376 (1953).</li><li>Abando, A., Hood, D., Weaver, F., Katz, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+the+Angioseal+device+for+femoral+artery+closure.">The use of the Angioseal device for femoral artery closure.</a> J Vasc Surg. 40 (2), 287-290 (2004).</li><li>Deshaies, E. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimodality+intraoperative+neurophysiological+monitoring+during+Onyx+embolization+of+cerebrovascular+malformations.">Multimodality intraoperative neurophysiological monitoring during Onyx embolization of cerebrovascular malformations.</a> Neurodiagn J. 55 (1), 12-24 (2015).</li><li>Vi&#241;uela, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Combined+endovascular+embolization+and+surgery+in+the+management+of+cerebral+arteriovenous+malformations:+experience+with+101+cases.">Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases.</a> J Neurosurg. 75 (6), 856-864 (1991).</li></ol>

科持有 Covidien 医师培训的咨询安排。科没有与这项工作有关的直接财务利益。其余的作者对本研究中使用的材料或方法或本文所述的结果没有披露。

在这里, 我们展示了一个综合的方法, 脑车辆通过联合血管内和开放式手术管理。导管血管造影是成像车辆的金标准, 对手术评估和规划具有重要的价值。手术前栓塞可以简化手术切除, 但需要与外科和介入治疗组之间的沟通, 以制定一个最佳的战略方法。例如, AVM 动脉馈线最容易栓塞也可能是最外科手术。然而, 如果他们是栓塞之前制定一个全面的治疗计划, 只留下更深更难获得动脉馈线, 手术变得...

脑动静脉畸形 (车辆), 动脉和静脉之间的异常连接不干预正常毛细血管床, 目前独特的神经外科的挑战。根据大小, 存在深引流静脉, 并参与雄辩皮质,1出血的风险以前破裂车辆范围从0.9 到8% 每年,2 , 每年平均破裂风险为3%。3车辆的出血与近10% 的死亡率和显著的发病率有关, 其中多达34% 的患者有中度至严重残疾。4先前破裂的车辆增加了年出血率,2 , 但复的即时风险相对较低。除非血肿的质量影响需要急性干预, 否则治疗通常是在权衡了预期的自然病史与治疗相关的风险之后进行的。5,6
外科手术切除是治疗选择的小车辆, 因为它立即和明确地消除未来出血的风险。然而, 高流速的车辆, 以及增加风险的 AVM 相关动脉瘤,4,7 , 使外科手术切除最具挑战性的所有神经外科病例。术前栓塞车辆, 以减少血流量和消除高危 AVM 的特点, 可以大大减少技术挑战的切除。
综合训练的血管外科是唯一的定位, 以明确治疗车辆通过进行术前血管造影和血管内栓塞, 以及开放手术切除。在这里, 我们描述的管理协议的外科手术可及性脑车辆 (根据确定的评分等级1,8以及外科医生和多学科会议评价) 在我们的机构。

<table><tbody><tr><td>ChloraPrep Sterilization Solution</td><td>BD, Franklin Lakes, NJ</td><td>260815</td><td>For skin sterilization</td></tr><tr><td>Lidocaine Hcl 1%</td><td>ACE Surgical Supply, Inc, Brockton, MA</td><td>001-1421</td><td>For local anesthetic</td></tr><tr><td>Micropuncture Groin Access Kit</td><td>Cook Medical, Bloomington, IN</td><td>G56202</td><td>Used for femoral artery access</td></tr><tr><td>0.035 Guidewire</td><td>Terumo Medical, Somerset, NJ</td><td>GR3506</td><td>Used in conjunction with diagnostic catheters for cerebral angiography</td></tr><tr><td>Cerebral Angiography Diagnostic Catheters</td><td>Terumo Medical, Somerset, NJ</td><td>CG416</td><td>Used in conjunction with guidewire for cerebral angiography</td></tr><tr><td>Omnipaque Contrast Agent</td><td>GE Healthcare, Chicago, IL</td><td>Q9965</td><td>Contrast agent for cerebral vessel imaging</td></tr><tr><td>Microcatheter and Microwire</td><td>Covidian, Plymouth, MN</td><td>105-5091-150, 103-0608</td><td>Used for distal arterial catheterization</td></tr><tr><td>Onyx Liquid Embolic</td><td>Covidian, Plymouth, MN</td><td>105-7100-060</td><td>Used for AVM embolization</td></tr><tr><td>Angio-Seal Vascular Closure Device</td><td>St. Jude Medical, St Paul, MN</td><td>610130</td><td>Used for femoral artery closure following angiography/intra-arterial embolization</td></tr><tr><td>Midas Rex High Power Drill System</td><td>Medtronic, Minneapolis, MN</td><td>PM700</td><td>Used for craniotomy</td></tr><tr><td>Matchstick Drill Bit</td><td>Medtronic, Minneapolis, MN</td><td>10MH30-MN</td><td>Used to create burr hole for craniotomy</td></tr><tr><td>Tapered Drill Bit</td><td>Medtronic, Minneapolis, MN</td><td>F1/8TA15</td><td>Used to complete craniotomy</td></tr><tr><td>#11 and 15 Blade Surgical Scalpels</td><td>BD Bard-Parker, Franklin Lakes, NJ</td><td>372615</td><td>Used for groin incision for angiography and dural opening for external ventricular drain placement or AVM resection</td></tr><tr><td>Metzenbaum Dissecting Scissors</td><td>Stoelting Co, Wood Dale, IL</td><td>52134-01P</td><td>Used for dural opening</td></tr><tr><td>Bone Elevator</td><td>Stoelting Co, Wood Dale, IL</td><td>52169</td><td>Used for separating dura from the inner skull</td></tr><tr><td>Gerald Forceps</td><td>Stoelting Co, Wood Dale, IL</td><td>52106-52</td><td>Used for dural opening and manipulation</td></tr><tr><td>Microsurgical Instruments</td><td>Accurate Surgical &amp;amp; Scientific Instruments Corporation, Westbury, NY</td><td>ASSI.BML1</td><td>Used for AVM microsurgical resection</td></tr><tr><td>Bipolar Forceps</td><td>Accurate Surgical &amp;amp; Scientific Instruments Corporation, Westbury, NY</td><td>ASSI.BPNS20423FP</td><td>Used for AVM microsurgical resection</td></tr><tr><td>Electrosurgery Generator</td><td>Bovie Medical Products, Clearwater, FL</td><td>IDS-200</td><td>Used for electrosurgical cutting/coagulation</td></tr><tr><td>Small Aneurysm Clips</td><td>Codman Neuro, Raynham, MA</td><td>20-1801</td><td>Used for occlusion of arterial AVM feeders not amenable to coagulation</td></tr><tr><td>Brain Retractors</td><td>Medicon, Tuttlingen, Germany</td><td>22.00.06</td><td>For brain retraction for deep AVM dissection/resection</td></tr><tr><td>Variable Action Suction tip</td><td>Millennium Surgical, Narberth, PA</td><td>6-8607</td><td>For suction with AVM dissection/resection</td></tr><tr><td>Fibrillar Absorbable Hemostatic Agent</td><td>Ethicon, Somerville, NJ</td><td>63713-0019-61</td><td>For hemostatis within surgical cavity</td></tr><tr><td>4-0 Suture</td><td>Ethicon, Somerville, NJ</td><td>C554D</td><td>For dural closure</td></tr><tr><td>2-0 Absorbable Suture</td><td>Ethicon, Somerville, NJ</td><td>J286G</td><td>For deep tissue closure</td></tr><tr><td>3-0 Nylon Suture</td><td>Ethicon, Somerville, NJ</td><td>ET-663G</td><td>For skin closure</td></tr><tr><td>Surgical Staples</td><td>Medline, Mundelein, IL</td><td>STAPLER35RB</td><td>For skin closure</td></tr><tr><td>Bone Plating System</td><td>Biomet, Warsaw, IN</td><td>15-7378-12</td><td>For bone flap securement</td></tr><tr><td>Operating Microscope</td><td>Leica Microsystems, Buffalo Grove, IL</td><td>M720 OH5</td><td>Used for AVM microsurgical resection</td></tr><tr><td>BrainLab Neuronavigation Imaging System</td><td>Brainlab, Inc, Chicago, IL</td><td>Brainlab Curve&amp;nbsp;</td><td>Used for AVM microsurgical resection</td></tr><tr><td>Lumbar External Drainage System</td><td>Codman Neuro, Raynham, MA</td><td>K964923</td><td>Used for placement of lumbar drain for CSF drainage</td></tr><tr><td>External Ventricular Drainage Catheter</td><td>Medtronic, Minneapolis, MN</td><td></td><td>Used for placement of ventricular catheter for CSF drainage</td></tr><tr><td>Disposable Raney Scalp Clips</td><td>A&amp;amp;E Medical Corporation, Farmingdale, NJ</td><td>070-001</td><td>Used for scalp hemostasis</td></tr></tbody></table>

comprehensive endovascular and open surgical management of cerebral arteriovenous malformations

Arteriovenious 畸形 (车辆) 与显著的发病率和死亡率相关, 并有每年3% 的破裂风险。治疗车辆必须专门针对病变, 手术切除是金标准的小, 容易接近的病变。预手术栓塞车辆可以减少尼达尔血流量, 消除高危的 AVM 功能, 如 intranidal 或静脉动脉瘤, 从而简化了一个具有挑战性的神经外科手术。在此, 我们描述了我们的方法进行分期血管内栓塞和开放切除车辆, 并强调了优势, 有全面训练的神经血管外科医生领导一个多学科的临床团队。这包括计划开颅手术和切除术, 立即跟随最后的栓塞阶段, 从而使用一个单一的麻醉期, 积极栓塞, 并迅速切除。最后, 我们提供了一个有代表性的情况下, 22-year-old 女性与破裂右额动静脉畸形诊断在癫痫发作检查, 谁成功治疗通过分期栓塞后, 开放手术切除。

一个 22-year-old 前健康女性提出新的发作发作。非对比头颅 CT 对急性出血呈阴性, 但表现为右额病变不完全特征。MRI 显示在右上额脑回 (图 1) 内有大约 2.9 x 2.4 cm Spetzler-马丁级 3 AVM, 有大量引流皮质静脉到上矢状窦, 通过右大分支的动脉供血大脑中动脉病人进行了多次分期血管内栓塞, 最终在栓塞的右脑前动脉蒂 (图 2)。在完成这些分期栓塞有剩余供...

Watch this Scientific Journal Video about Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations at JoVE.com

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

手术是 arteriovenious 畸形 (车辆) 的金标准, 术前栓塞可以简化这一过程。我们描述我们的方法进行分期血管内栓塞和开放切除车辆, 并提供一个有代表性的临床例子突出的优势, 全面训练的神经血管外科医生领导的多学科临床团队.

脑动静脉畸形的综合血管内和开放性手术治疗

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

comprehensive-endovascular-open-surgical-management-cerebral

Research

JoVE Journal

Neuroscience

9.5K 次观看.  University of California, San Diego. 手术是 arteriovenious 畸形 (车辆) 的金标准, 术前栓塞可以简化这一过程。我们描述我们的方法进行分期血管内栓塞和开放切除车辆, 并提供一个有代表性的临床例子突出的优势, 全面训练的神经血管外科医生领导的多学科临床团队.

视频: Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Microsurgical Venous Pouch Arterial-Bifurcation Aneurysms in the Rabbit Model: Technical Aspects

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials have shown disappointing long-term results with unacceptable high rates of aneurysm recanalization and delayed aneurysm rupture.2 To overcome these problems, animal experimental studies are crucial for the development of better endovascular devices.3-5
Several animal models in rats, rabbits, canines and swine are available.6-8 Comparisons of the different animal models showed the superiority of the rabbit model with regard to hemodynamics and comparability of the coagulation system and cost-effectiveness.9-11 
The venous pouch arterial bifurcation model in rabbits is formed by a venous pouch sutured into an artificially created true bifurcation of both common carotid arteries (CCA). The main advantage of this model are true bifurcational hemodynamics.12 The major drawbacks are the sofar high microsurgical technical demands and high morbidity and mortality rates of up to 50%.13 These limitations have resulted in less frequent use of this aneurysm model in the recent years. These shortcomings could be overcome with improved surgical procedures and modified peri- and postoperative analgetic management and anticoagulation.14-16 Our techniques reported in this paper demonstrate this optimized technique for microsurgical creation of arterial bifurcation aneurysms.

An optimized technique for the microsurgical creation of arterial bifurcation aneurysms mimicking bifurcation human cerebral aneurysms is described. A venous pouch is sutured into an artificially created true bifurcation of both common carotid arteries. Facilitated microsurgical techniques and aggressive postoperative anticoagulation and analgesia lead to minimized morbidity rates and high aneurysm patency rates.

显微静脉袋分岔动脉瘤在兔模型：技术问题

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials ...

科研

医学

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow (ischemia) 1. Middle cerebral artery (MCA) delivers a great majority of blood to the lateral surface of the cortex 2, is the most common site of human stroke 3, and ischemia within its territory can result in extensive dysfunction or death 1,4,5. Survivors of ischemic stroke often suffer loss or disruption of motor capabilities, sensory deficits, and infarct. In an effort to capture these key characteristics of stroke, and thereby develop effective treatment, a great deal of emphasis is placed upon animal models of ischemia in MCA.
Here we present a method of permanently occluding a cortical surface blood vessel. We will present this method using an example of a relevant vessel occlusion that models the most common type, location, and outcome of human stroke, permanent middle cerebral artery occlusion (pMCAO). In this model, we surgically expose MCA in the adult rat and subsequently occlude via double ligature and transection of the vessel. This pMCAO blocks the proximal cortical branch of MCA, causing ischemia in all of MCA cortical territory, a large portion of the cortex. This method of occlusion can also be used to occlude more distal portions of cortical vessels in order to achieve more focal ischemia targeting a smaller region of cortex. The primary disadvantages of pMCAO are that the surgical procedure is somewhat invasive as a small craniotomy is required to access MCA, though this results in minimal tissue damage. The primary advantages of this model, however, are: the site of occlusion is well defined, the degree of blood flow reduction is consistent, functional and neurological impairment occurs rapidly, infarct size is consistent, and the high rate of survival allows for long-term chronic assessment.

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

We describe a highly reproducible method for the permanent occlusion of a rodent major cerebral blood vessel. This technique can be accomplished with very little peripheral damage, minimal blood loss, a high rate of long-term survival, and consistent infarct volume commensurate with the human clinical population.

永久性脑血管闭塞<em&gt;通过</em&gt;双人结扎横断

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow ...

Adult Mouse Venous Hypertension Model: Common Carotid Artery to External Jugular Vein Anastomosis.

The understanding of the pathophysiology of brain arteriovenous malformations and arteriovenous fistulas has improved thanks to animal models. A rat model creating an artificial fistula between the common carotid artery (CCA) and the external jugular vein (EJV) has been widely described and proved technically feasible. This construct provokes a consistent cerebral venous hypertension (CVH), and therefore has helped studying the contribution of venous hypertension to formation, clinical symptoms, and prognosis of brain AVMs and dural AVFs. Equivalent mice models have been only scarcely described and have shown trouble with stenosis of the fistula. An established murine model would allow the study of not only pathophysiology but also potential genetic therapies for these cerebrovascular diseases.
We present a model of arteriovenous fistula that produces a durable intracranial venous hypertension in the mouse. Microsurgical anastomosis of the murine CCA and EJV can be difficult due to diminutive anatomy and frequently result in a non-patent fistula. In this step-by-step protocol we address all the important challenges encountered during this procedure. Avoiding excessive retraction of the vein during the exposure, using 11-0 sutures instead of 10-0, and making a carefully planned end-to-side anastomosis are some of the critical steps. Although this method requires advanced microsurgical skills and a longer learning curve that the equivalent in the rat, it can be consistently developed.
This novel model has been designed to integrate transgenic mouse techniques with a previously well-established experimental system that has proved useful to study brain AVMs and dural AVFs. By opening the possibility of using transgenic mice, a broader spectrum of valid models can be achieved and genetic treatments can also be tested. The experimental construct could also be further adapted to the study of other cerebrovascular diseases related with venous hypertension such as migraine, transient global amnesia, transient monocular blindness, etc.

We describe a method for creating a reliable model of cerebral venous hypertension in the adult mouse. This model has been widely described and tested in the rat. This new counterpart in the mice opens the possibility of using genetic modified animals and thereby broadens the applications of the model.

成年小鼠静脉高压型号:颈总动脉，以颈外静脉吻合。

The understanding of the pathophysiology of brain arteriovenous malformations and arteriovenous fistulas has improved thanks to animal models. A rat model ...

Microsurgical Clip Obliteration of Middle Cerebral Aneurysm Using Intraoperative Flow Assessment

Cerebral aneurysms are abnormal widening or ballooning of a localized segment of an intracranial blood vessel.  Surgical clipping is an important treatment for aneurysms which attempts to exclude blood from flowing into the aneurysmal segment of the vessel while preserving blood flow in a normal fashion.  Improper clip placement may result in residual aneurysm with the potential for subsequent aneurysm rupture or partial or full occlusion of distal arteries resulting in cerebral infarction.  Here we describe the use of an ultrasonic flow probe to provide quantitative evaluation of arterial flow before and after microsurgical clip placement at the base of a middle cerebral artery aneurysm.  This information helps ensure adequate aneurysm reconstruction with preservation of normal distal blood flow.

Description of the surgical obliteration of a cerebral aneurysm utilizing an ultrasonic flow probe to assess arterial flow prior to and after aneurysm clip placement.

显微剪辑闭塞大脑中动脉瘤术中流量评估

Cerebral aneurysms are abnormal widening or ballooning of a localized segment of an intracranial blood vessel.  Surgical clipping is an important ...

生物学

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients &#8804;55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged &#8804;55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Minimally invasive thumb-sized pterional craniotomy for aneurysm clipping has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

微创拇指大小翼点入开颅未破裂前循环动脉瘤的手术夹子结扎

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

Isolation and Cannulation of Cerebral Parenchymal Arterioles

Intracerebral parenchymal arterioles (PAs), which include parenchymal arterioles, penetrating arterioles and pre-capillary arterioles, are high resistance blood vessels branching out from pial arteries and arterioles and diving into the brain parenchyma. Individual PA perfuse a discrete cylindrical territory of the parenchyma and the neurons contained within. These arterioles are a central player in the regulation of cerebral blood flow both globally (cerebrovascular autoregulation) and locally (functional hyperemia). PAs are part of the neurovascular unit, a structure that matches regional blood flow to metabolic activity within the brain and also includes neurons, interneurons, and astrocytes. Perfusion through PAs is directly linked to the activity of neurons in that particular territory and increases in neuronal metabolism lead to an augmentation in local perfusion caused by dilation of the feed PA. Regulation of PAs differs from that of better-characterized pial arteries. Pressure-induced vasoconstriction is greater in PAs and vasodilatory mechanisms vary. In addition, PAs do not receive extrinsic innervation from perivascular nerves &#8212; innervation is intrinsic and indirect in nature through contact with astrocytic endfeet. Thus, data regarding contractile regulation accumulated by studies using pial arteries does not directly translate to understanding PA function. Further, it remains undetermined how pathological states, such as hypertension and diabetes, affect PA structure and reactivity. This knowledge gap is in part a consequence of the technical difficulties pertaining to PA isolation and cannulation. In this manuscript we present a protocol for isolation and cannulation of rodent PAs. Further, we show examples of experiments that can be performed with these arterioles, including agonist-induced constriction and myogenic reactivity. Although the focus of this manuscript is on PA cannulation and pressure myography, isolated PAs can also be used for biochemical, biophysical, molecular, and imaging studies.

This manuscript describes a simple and reproducible protocol for isolation of intracerebral arterioles (a group of blood vessels encompassing parenchymal arterioles, penetrating arterioles and pre-capillary arterioles) from mice, to be used in pressure myography, immunofluorescence, biochemistry, and molecular studies.

分离及脑实质小动脉插管

Intracerebral parenchymal arterioles (PAs), which include parenchymal arterioles, penetrating arterioles and pre-capillary arterioles, are high resistance ...

神经科学

Surgical Approach for Middle Cerebral Artery Occlusion and Reperfusion Induced Stroke in Mice

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ischemic in origin and occur in the territory of the middle cerebral artery (MCA). Currently the only Food and Drug Administration (FDA) approved drug for the treatment of this devastating disease is tissue plasminogen activator (tPA). However, tPA has a small therapeutic window for administration (3 - 6 hr), and is only effective in 4% of the patients who actually receive it. Current research focuses on understanding the pathophysiology of stroke in order to find potential therapeutic targets. Thus, reliable models are crucial, and the MCA occlusion (MCAo) model (also termed the intraluminal filament or suture model) is deemed to be the most clinically relevant surgical model of ischemic stroke, and is fairly non-invasive and easily reproducible. Typically the MCAo model is used with rodents, especially with mice due to all the genetic variations available for this species. Here we describe (and present in the video) how to successfully perform the MCAo model (with reperfusion) in mice to generate reliable and reproducible data.

In order to understand the pathophysiology of stroke, it is important to use reliable models. This paper will describe one of the most frequently used stroke models in mice, termed the middle cerebral artery occlusion (MCAo) model (also termed the intraluminal filament or suture model) with reperfusion.

对大脑中动脉闭塞再灌注损伤诱发中风小鼠的手术方法

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ...

Simulator Training for Endovascular Neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

血管内神经外科模拟器培训

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

Transvenous Embolization of Carotid Cavernous Fistula through Inferior Petrosal Sinus with Detachable Coils and Ethylene Vinyl Alcohol Copolymer

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal branches of the external carotid artery (indirect fistula) and the cavernous sinus (CS). Trauma is the most common cause of CCF. The clinical presentation of CCF is closely related to the venous drainage pattern. Orbital and neuro-ophthalmological symptoms are the most common clinical presentation of CCF with drainage through the superior ophthalmic vein (SOV). Endovascular embolization by arterial or venous approaches is the most common management of CCF. Transvenous embolization using detachable coils and ethylene-vinyl alcohol copolymer (EVOH) is an alternative method for the treatment of CCF. Endovascular embolization offers different options to treat CCF by minimally invasive approach decreasing morbidity and residual fistulas. The purpose of this article is to report our treatment experiences via the inferior petrosal sinus (IPS), and immediate-term outcomes of endovascular embolization of CCF by using detachable coils and EVOH.

The purpose of the article is to present our experience in endovascular treatment via the inferior petrosal sinus of the carotid cavernous fistula with detachable coils and ethylene-vinyl alcohol copolymer.

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal ...

Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ventriculoperitoneal (VP) shunt is the most common type. Unfortunately, the failure rates of VP shunts are alarmingly high, with up to 50% of patients requiring revision surgery within 2 years. VP shunt failure may occur due to infection, or catheter mispositioning, migration, and occlusion. We undertook a joint neurosurgery and general surgery collaboration in a 7-year prospective non-randomized consecutive quality improvement cohort study to reduce the rates of ventriculoperitoneal (VP) shunt failures in 224 adult patients at a tertiary care institution. The initiative combined the use of electromagnetic stereotactic neuronavigation to guide the placement of the proximal catheter and laparoscopy to place the distal catheter under direct visualization. With laparoscopic assistance, the distal catheter was anchored through a small hole created in the falciform ligament and placed into the right retrohepatic space, free from the omentum, adhesions, or bowel that might obstruct the catheter tip. The surgeries were performed using a shunt infection prevention protocol to reduce the risk of shunt infections. Here, we present an intraoperative video of the surgical procedure. Compliance with shunt infection reduction strategies and the combined utilization of neuronavigation and laparoscopy techniques in adult VP shunt surgery resulted in a 44% reduction in the risk of overall shunt failure. The significant positive impact with regard to shunt-failure-free patient outcomes among patients who underwent VP shunt surgery using this strategy underscores the value associated with the use of these modern intraoperative techniques and cross-specialty collaboration during VP shunt surgery.

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively.

脑动静脉畸形的综合血管内和开放性手术治疗

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