脳動静脈奇形摘出術の基本戦略

Abstract

We describe basic surgical strategy and techniques for resection of cerebral arteriovenous malformations (AVMs). Understanding of the vascular structure of AVMs is important to plan surgical strategies for AVMs. The craniotomy should be large enough as to expose all the structures of the AVMs, such as nidus, feeders and drainers. In the first step of surgery, feeders are secured to control bleeding and to reduce tension of the nidus and drainers. Preoperative occlusion of the hidden feeders by endovascular surgery is a useful option. For an approach to the buried nidus, retrograde dissection of the main drainer is effective. When bleeding is difficult to control during dissection of the nidus, the dissection plane has got into the nidus and should be reset outward. Feeding arteries are coagulated and cut after they are confirmed to contribute to the AVM. The main drainer should be preserved up to the final step of the resection. Intraoperative angiography is useful to identify the feeders and to confirm the residuals of the AVM.