ガレン静脈瘤様形態を示した脳動脈奇形の1治験例

Arteriovenous Malformation Resembling Galenic Aneurysm

I．はじめに

　脳動静脈奇形（AVM）のうち深部正中部に発生するものの代表例としてガレン静脈瘤（VGA）が挙げられる．これらの症例における治療はきわめて困難であり，従って予後も不良である．原因の一つとしては，血管異常が解剖学的に深部に存在すること，high flowなことなどが挙げられる^4,9）．しかし，近年血管内外科の進歩に伴い，術前にembolizationを行うことにより比較的安全に手術へと治療を進めることが可能になってきた^{1,2,6-9，13,14）}．今回われわれは還流静脈こそガレン静脈（VoG）ではないが．形態的にきわめて類似した脳動脈奇形に対して，2回のembolization後に手術を施行し，根治せしめたので報告する．

A girl who had just turned one your old was trans-ported to our hospital because of an episode of general convulsive seizure. Neurological examinations demon-strated a comatose consciousness level, moderate right hemiparesis and conjugate deviation to the right. CT scan on admission revealed an intracerebral hematoma in the left medial temporal lobe associated with in-traventricular hemorrhage in the lateral and third ventri-cles. MRI also showed the hematoma with evidence of a dilated venous system. Angiography demonstrated a huge venous sac fed by the left posterior choroidal artery and left anterior choroidal artery drained ultimately into the remnant of the tentorial sinus. Firstly, two courses of transfemoral embolization using platinum micro-coils were performed. Initially, the posterior choroidal artery and a branch of the anterior choroidal artery were occluded successfully. Then, two branches from the pos-terior cerebral artery were occluded one week after the initial procedure. She underwent the operation via the left subtemporal approach. After the CSF removal through the Sylvian fissure, the gentle elevation of the left temporal lobe allowed the visualization of the feeders and the pulsating venous sac. After the complete obli-teration of the feeding arteries and removal of the nidus, the interruption was verified by using doppler sonogra-phy and intraoperative angiography. Postoperative course was uneventful. The infant was discharged with-out deficit on the 30th postoperative day. The authors discussed the embryological implications of this type of AVM and the role of endovascular surgery.