[Demonstration of a vascular lesion by intraoperative portable DSA in a case of intracerebral hematoma with impending herniation].

ABSTRACT

A nine year old boy with sudden onset of loss of consciousness was brought to the emergency room where he was in deep coma with bilateral decerebrated rigidity, and fixed dilated pupils. Computerized tomographic scan showed an intracerebral hematoma in the left temporal lobe associated with signs of uncal herniation. He was taken to the operating room immediately and craniotomy was started. After aspirating a small amount of hematoma through a burr hole, left carotid angiography was carried out by using a portable digital subtraction angiography (DSA) unit. The procedure took approximately ten minutes, and it showed arteriovenous malformation (AVM) supplied by a temporal branch of the middle cerebral artery. Using this angiogram as a guide, the intracerebral hematoma and the AVM were completely removed. The patient recovered well and returned to school after rehabilitation. This case illustrates a method of treatment for intracerebral hematoma with impending herniation. Although, in general, preoperative angiography is required before the operation of AVM, it could be argued that time spent for angiography may result in irreversible damage to the brain stem in the presence of uncal herniation. We chose to perform intraoperative portable DSA during evacuation of the hematoma instead of wasting time on preoperative angiography. With this method, we were not only able to remove the hematoma without delay, but were also able to extirpate the AVM safely. Whether or not our method can be used in general remains to be seen, and further experience is required.