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1.
J Neurosurg ; 122(1): 107-17, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25343188

RESUMO

OBJECT: The surgical management of brainstem arteriovenous malformations (AVMs) might benefit from the definition of anatomical subtypes and refinements of resection techniques. Many brainstem AVMs sit extrinsically on pia mater rather than intrinsically in the parenchyma, allowing treatment by occluding feeding arteries circumferentially, interrupting draining veins after arteriovenous shunting is eliminated, and leaving the obliterated nidus behind. The authors report here the largest series of brainstem AVMs to define 6 subtypes, assess this "occlusion in situ" technique, and analyze the microsurgical results. METHODS: Brainstem AVMs were categorized as 1 of 6 types: anterior midbrain, posterior midbrain, anterior pontine, lateral pontine, anterior medullary, and lateral medullary AVMs. Data from a prospectively maintained AVM registry were reviewed to evaluate multidisciplinary treatment results. RESULTS: During a 15-year period, the authors treated 29 patients with brainstem AVMs located in the midbrain (1 anterior and 6 posterior), pons (6 anterior and 7 lateral), and medulla (1 anterior and 8 lateral). The nidus was pial in 26 cases and parenchymal in 3 cases. Twenty-three patients (79%) presented with hemorrhage. Brainstem AVMs were either resected (18 patients, 62%) or occluded in situ (11 patients, 38%). All lateral pontine AVMs were resected, and the occlusion in situ rate was highest with anterior pontine AVMs (83%). Angiography confirmed complete obliteration in 26 patients (89.6%). The surgical mortality rate was 6.9%, and the rate of permanent neurological deterioration was 13.8%. At follow-up (mean 1.3 years), good outcomes (modified Rankin Scale [mRS] score ≤ 2) were observed in 18 patients (66.7%) and poor outcomes (mRS score of 3-5) were observed in 9 patients (33.3%). The mRS scores in 21 patients (77.8%) were unchanged or improved. The best outcomes were observed with lateral pontine (100%) and lateral medullary (75%) AVMs, and the rate of worsening/death was greatest with posterior midbrain and anterior pontine AVMs (50% each). CONCLUSIONS: Brainstem AVMs can be differentiated by their location in the brainstem (midbrain, pons, or medulla) and the surface on which they are based (anterior, posterior, or lateral). Anatomical subtypes can help the neurosurgeon determine how to advise patients, with lateral subtypes being a favorable surgical indication along with extrinsic pial location and hemorrhagic presentation. Most AVMs are dissected with the intention to resect them, and occlusion in situ is reserved for those AVMs that do not separate cleanly from the brainstem, that penetrate into the parenchyma, or are more anterior in location, where it is difficult to visualize and preserve perforating arteries (anterior pontine and lateral medullary AVMs). Although surgical morbidity is considerable, surgery results in a better obliteration rate than nonoperative management and is indicated in highly selected patients with high rerupture risks.


Assuntos
Tronco Encefálico/patologia , Tronco Encefálico/cirurgia , Revascularização Cerebral/métodos , Malformações Arteriovenosas Intracranianas/patologia , Malformações Arteriovenosas Intracranianas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Malformações Arteriovenosas Intracranianas/classificação , Masculino , Bulbo/patologia , Bulbo/cirurgia , Pessoa de Meia-Idade , Ponte/patologia , Ponte/cirurgia , Resultado do Tratamento , Adulto Jovem
2.
Klin Wochenschr ; 66 Suppl 14: 19-26, 1988.
Artigo em Alemão | MEDLINE | ID: mdl-3392898

RESUMO

Based on a series of 95 neurosurgical spinal cord monitoring cases with space-occupying lesions, most of which were monitored using both spinal and cortical recordings, the use and the limits of intraoperative monitoring of sensory pathway function of the spinal cord is described. Intraoperative spinal cord monitoring performed by recording of somatosensory evoked potentials following peripheral nerve or intrathecal stimulation is shown to be a useful adjunct in cases of difficult spinal cord surgery. In our own material using both spinal and cortical recordings there have been no false-negative monitoring cases so far. In the discussion the limitations and pitfalls of this technique are reviewed.


Assuntos
Eletroencefalografia , Complicações Intraoperatórias/fisiopatologia , Neoplasias da Medula Espinal/cirurgia , Medula Espinal/fisiopatologia , Neoplasias Encefálicas/cirurgia , Estimulação Elétrica , Potenciais Somatossensoriais Evocados , Humanos , Nervo Mediano/fisiopatologia , Bulbo/cirurgia , Microcirurgia , Nervo Fibular/fisiopatologia , Processamento de Sinais Assistido por Computador , Nervo Tibial/fisiopatologia
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