Cerebrovascular Malformation Surgery

Cerebrovascular malformation is a congenital vascular dysplasia in the early stage of the embryo. It can be divided into five categories according to its morphology, namely arteriovenous malformation, venous aneurysm, varicose veins, telangiectasia and cavernous hemangioma. Arteriovenous malformations are most common in cerebrovascular malformations. Cerebral vascular malformation is also called cerebral hemangioma, cerebral arteriovenous malformation. It is not a true tumor, but it is customarily included in intracranial tumors, accounting for 1.5% to 4%. The purpose of cerebral arteriovenous malformation surgery is to prevent rebleeding, relieve epilepsy, treat or improve nervous system dysfunction. Treatment of diseases: cerebral vascular malformation epilepsy Indication 1. The patient has one of the following conditions, and the angiographic examination determines that the deformed blood vessel can be removed: (1) History of spontaneous subarachnoid hemorrhage. (2) Frequent epilepsy, poor drug treatment. (3) Patients with progressive neurological localization damage or mental retardation (stolen blood syndrome). (4) Patients with intracranial hematoma or intracranial hypertension. 2. The following surgical methods can be used to treat: (1) Hematoma removal surgery, suitable for patients with hematoma after hemorrhage. If the patient is in good condition, cerebral angiography can be performed before surgery, and malformation can be performed simultaneously during the operation. If the condition is critical, the hematoma can be removed first, and the cerebral angiography is performed after the condition is restored, and the second operation is performed for the lesion resection. (2) malformation vascular resection, suitable for those who have had bleeding, especially repeated bleeding; due to brain thief blood phenomenon, progressive hemiparesis and other progressive brain dysfunction and intractable seizures and drugs difficult to control. (3) Supply of arterial ligation, suitable for deep in the lesion, involving important structures such as the brain stem, deep veins and so on. However, there are a number of supply arteries, and only one or two of them are ligated, which may not be therapeutic. (4) Artificial embolization, suitable for extensive or multiple lesions can not be removed, or used as a preparatory surgery before extensive vascular malformation. Contraindications Both are relative contraindications, and with the improvement of technology, some of them can still be treated surgically. 1. Arteriovenous malformations in the deep brain, internal capsule, basal ganglia, brainstem, etc. 2. Extensive or multiple arteriovenous malformations. 3. Asymptomatic. 4. Older people over 60 years old, with severe heart, kidney and respiratory diseases. Preoperative preparation 1. Due to the possibility of multiple cerebral angiography or bilateral carotid angiography before surgery, or according to the location of deformed blood vessels, plus vertebral artery angiography. Typical cerebral arteriovenous malformations include the supply of arteries, malformations, and drainage veins. Through angiography, it is necessary to find out the source of the artery and the direction of the drainage vein, the location and extent of the deformity, whether there is a hematoma and other complications, and whether the patient is deformed or not, in order to develop a perfect surgical plan, which is also the key to successful surgery. 2. For complex arteriovenous malformations, in order to deal with intraoperative hemorrhage, blood preparation should be sufficient (larger cerebral arteriovenous malformation should be prepared for blood 1500 ~ 2000ml), hemostasis equipment and drugs need to be complete, can prepare two sets of suction . Prepare two intravenous infusions before surgery and prepare arterial blood transfusion equipment. Dosing before general anesthesia. 3. If necessary, the operation should be performed on an operating table that can be angiographically, so that intraoperative angiography is necessary if necessary. Surgical procedure 1. Preparative surgery: For the operation of the carotid artery and its branches to the arteries of the cerebral arteriovenous malformation, during the operation to control the blood supply to the carotid artery, the supine position is taken and the head is turned to the healthy side. After local anesthesia, a longitudinal incision is made along the anterior border of the sternocleidomastoid in the thyroid cartilage plane. The platysma was cut open, the sternocleidomastoid muscle was pulled open, the carotid sheath was incised, the internal carotid artery was isolated, and the rubber ring was bypassed, but the blood flow was not blocked. The incision is inserted into the dry gauze to protect it for temporary control of bleeding if necessary. 2. Position, incision (take more common cerebral hemisphere frontal lobe lesions as an example): the patient is lying on the side, making a large horseshoe-shaped incision at the top of the forehead, the front should be able to reveal the central anterior gyrus, and the entire lesion should be included in the surgical field, the incision The midline is on the sagittal line to reveal the longitudinal division of the cerebral hemisphere. 3. Craniotomy: According to the scalp skull flap craniotomy, but pay attention to the following points: 1 scalp, skull bleeding often, sometimes like meningioma, so the scalp should be segmented and cut, carefully stop bleeding; scalp and bone flap can be opened separately. 2 If the thick blood vessels in the central anterior gyrus and the dura mater are obviously adhered, do not barely open it, leaving a small dura mater. 3 If the bone flap has been torn, the blood vessel can be torn, and it can be compressed by a small muscle or gelatin sponge, and sutured on the dura mater. The blood vessel cannot be ligated, otherwise hemiplegia or epilepsy may occur after surgery. 4 After the formation of the scalp bone flap, the bleeding at the edge of the bone window is coated with bone wax, and the oozing vein and arachnoid granules are covered with brain cotton, which can stop bleeding and prevent the formation of air plug. 4. Identification of central gyrus and blood supply artery: The anatomical location alone to determine the exercise zone is not accurate enough, and can be identified by an electrical stimulator. The main blood supply artery diameter is thicker than that of normal arteries. The blood vessel wall is slightly thicker than the abnormal blood vessel wall. The main blood vessels in the blood vessels are arterial blood, which is consistent with the positioning on the contrast film. It can be determined according to the above conditions. However, sometimes due to the mixing of arterial and venous blood, the blood vessel wall itself is also defective. If it cannot be determined, the blood vessel can be clamped with a small forceps or an aneurysm clip and observed for a while. If the artery is arterial, the distal end will become blue vein blood; otherwise, if it is a venous vein, there is no such change. 5. Ligation of the blood supply artery: After determining the extent of the arteriovenous malformation in the cerebral cortex and the blood supply artery, the blood supply artery is clamped with a silver clip or the wire is ligated, but the blood vessel in the central anterior region of the supply should be retained. If the main blood supply artery is from the middle cerebral artery, the lateral fissure can be carefully separated to reveal the middle cerebral artery. The upper vascular clamp temporarily controls the blood supply for 6-8 minutes, and the branch that supplies the hemangioma is quickly separated, and the silver clip is cut off. Then release the small blood vessel clip. In short, the main blood supply artery should be ligated as much as possible, and the closer to the hemangioma, the better. At this time, it should be seen that the hemangioma becomes smaller and the vasoconstriction. If there is no contracture, the main blood supply artery should be considered in the deep part, and the separation should be noted and treated. 6. Separation of hemangioma: Around the hemangioma, electrocoagulation and incision of the cortex 3 to 4 mm deep (the artery with the silver clip should be cut off. Use the brain pressure plate (deep with a light brain plate or cold light source) And the suction device carefully separates and attracts under direct vision, but it must not blindly smash, so as not to cause turbulent bleeding. In the case of large blood vessels, the aneurysm needle strip is usually cut after double ligation. After electrocoagulation and cutting in the middle, the silver clip must be longer than the diameter of the blood vessel. If there is no large silver clip, the brain aneurysm clip can be used. Then the deformed lesion is separated and turned over, and the main blood supply blood vessel is found in the deep part. Can remove brain arteriovenous malformations. 7. Surgery of the tumor cavity: After the hemangioma is removed, the active bleeding point is stopped by bipolar coagulation or silver clip. Then put a bunch of wet brain cotton with a line, attract it with a suction device, and attach the brain cotton to the wall of the tumor wall. After a few minutes, carefully and slowly pick up the brain cotton, and use the bipolar electricity to patiently and carefully. Congestively stop bleeding. After repeated treatment, the bleeding will stop. Fill the tumor cavity with the normal saline before the skull is closed, and observe the presence or absence of oozing again; if yes, continue to treat until the physiological saline placed in the tumor cavity remains clear, and after removing the antihypertensive drug re-pressure or compressing the jugular vein Still no bleeding. 8. Guan skull: tightly sutured the dural brain, and the dura mater sutures the suture of the skull. The dura mater in the skull window is excessively relaxed. It can be used as a dura mater suspension line. A small hole is drilled from the corresponding part of the skull flap, and the suspending wire is led to the outside of the skull. The periosteum is sutured and sutured to eliminate the epidural space as much as possible. The opportunity for post-hematoma formation. A drainage tube was placed under the subdural and epidural and another incision was made.