巨大基底核部脳動静脈奇形の1治療例

Successful Treatment of Huge Arteriovenous Malformation in the Basal Ganglia

I．はじめに

　大脳基底核部の動静脈奇形（arteriovenous Malforma—tion以下AVMと略す）は，若年者で症状を有しているものは予後が悪く，保存的に治療すると，その50％以上が死亡，あるいは後遺症を残すといわれている^15）．従って外科的治療が大脳基底核部AVMに対しても望まれるわけであるが，解剖学的位置関係からこの部のAVMの直達手術は，極めて困難とされてきた．しかし，近年の血管内手術手技の進歩と相俟って今まで直達手術が困難とされていた症例に対しても，積極的な外科手術が試みられ手術成績そのものも向上してきている．

　今回，われわれは左基底核部high flow，巨大AVMに対し，超選択的塞栓術後，直達手術を行い，術後著明な神経症状の改善をみた1例を経験したので，若干の文献的考察を加えて報告する．

Abstract

This report describes successful therapeutic results of a huge and high flow arteriovenous malformation (AVM) in the left basal ganglionic region. A 39-year-old female was admitted to our hospital presenting re-cent progression of aphasia, hemianopsia, hemiparesis, hemisensory disturbance on the right side. Progression of disturbance in consciousness was rapid, and the pa-tient became comatose shortly after admission. A CT scan revealed a densely enhanced lesion in the left bas-al ganglia which caused aqueductal obstruction and hydrocephalus. Angiography demonstrated a huge and high flow AVM that was supplied by the anterior and posterior choroidal arteries, the lateral striate arteries and the insular branches of the middle cerebral arteries. This AVM drained into the vein of Galen via the in-ferior ventricular and basal vein. The draining vein was markedly dilatated at the level of midbrain by a prom-inent stenosis of the junction between the vein of Galen and straight sinus, and it severely compressed the mid-brain. Superselective embolization of the feeding arte-ries was clone in two sessions. This was followed by surgical intervention for the embolized AVM one month after the second session. Embolization and surgery were carried out under barbiturate protection to reduce the risk of normal perfusion pressure break-through. The patient recovered well from these in-terventions without any hemodynamic changes and showed dramatic improvement of all focal neurological abnormalities. Postoperative angiography showed only a small residue of AVM.