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（阅读本文前建议先回顾前篇--点击前面链接即可） The Lateral Temporal AVM 颞叶外侧面型AVM Temporal AVM subtypes include one for each surface: lateral temporal, basal temporal, sylvian temporal, and medial temporal. Lateral temporal lobe AVMs are based on or immediately beneath the lateral convexity (Fig. 12.4). These are the most common of all subtypes, and by far the most common temporal subtype, accounting for over two thirds of temporal AVMs. Superior temporal arteries from the inferior trunk of the MCA are the feeders to these lateral AVMs. The dominant feeding artery varies with the nidus location in the lateral temporal lobe, with the ATA and MidTempA feeding anterior temporal AVMs and PosTempA and TempOccA feeding posterior temporal AVMs. The MCA feeding arteries emanate from the sylvian fissure and intersect the nidus along its superior border. The ATA and TempPolA wrap around the temporal pole and intersect anteriorly. The PosTempA from the P2 PCA contributes to AVMs that are inferiorly located in the ITG. The AChA is involved with larger AVMs with an ependymal plane in the temporal horn. Venous drainage is superficial, with minor deep drainage only with larger AVMs. Drainage usually descends posteriorly through AntTempV, MidTempV, and PosTempV to the vein of Labbé and the TrvS, but may also ascend to TempSylV, SupSylV, and SphParS. Wernicke’s speech area is associated with lateral temporal AVMs in the STG beyond 5 cm from the temporal pole. 颞叶每一个表面都有一种AVM：颞叶外侧面、颞叶底面、颞叶侧裂面和颞叶内侧面。颞叶外侧面型AVM起源或接近大脑侧凸（lateral convexity）（图12.4），约占所有颞叶AVM的2/3以上，是所有类型中最常见的。发自MCA下干的颞上动脉，是颞叶外侧面型AVM的供血动脉。供应颞叶外侧面型AVM前部的颞前动脉（ATA）、颞中动脉（MidTempA），和供应其后部的颞后动脉（PosTempA）、颞枕动脉（TempOccA），都从颞叶外侧发出。侧裂放射状发出的MCA的供血支沿血管巢上缘穿行。颞前动脉（ATA）和颞中动脉（MidTempA）围绕颞极，在前方交叉走行。发自PCA的P2段的颞后动脉（PosTempA）位于颞下回（ITG）下方，供应AVM。大型AVM在下角处，有带有室管膜平面的AChA参与供血。静脉引流都很表浅，只有大的AVM有细小的深部引流。血流多半向后下通过AntTempV、MidTempV和PosTempV引向Labbé静脉和横窦（TrvS），也可以向上到颞叶侧裂静脉（TempSylV）、侧裂浅静脉（SupSylV）和蝶顶窦（SphParS）。颞上回（STG）里的颞叶外侧AVM，位于颞极上方5cm，与Wernicke语言区相关。 Fig. 12.4 The lateral temporal AVM subtype: (a) lateral and (b) superior cross-sectional views. This AVM is located on the lateral temporal surface, supplied by early temporal arteries from the M1 segment (ATA and TempPolA) and superior temporal arteries from the inferior MCA trunk, and drained by ascending and descending lateral temporal veins. 图12.4 颞叶外侧面型AVM（a）侧面和（b）上面截面观。这型AVM位于颞叶侧面，由早期发自M1段分支（ATA和TempPolA）和发自MCA下干的颞上动脉供血，向上或向下引流入颞叶外侧面静脉。 Temporal AVM Resection Strategies 颞叶AVM切除策略 Lateral Temporal AVM Resection 颞叶外侧面型AVM切除策略 Lateral temporal AVMs are convexity lesions that are the easiest temporal AVMs to expose. A pterional craniotomy is used for AVMs in front of the external auditory canal (one fourth of lateral AVMs), and a temporal craniotomy is used for AVMs behind the external auditory canal (EAC) (three fourths of lateral AVMs) (Fig. 12.8). 在所有的颞叶AVM中，颞叶外侧面型AVM病变凸出而最易于显露。外耳道前方的颞叶外侧面型AVM使用翼点入路（1/4），外耳道（EAC）后方采用颞瓣开颅（3/4）（图12.8 ）。 Fig. 12.8 Overview of temporal AVMs and their surgical approaches. (a) Temporal AVM subtypes and their angle of attack (parallel or perpendicular). Patients with temporal AVMs are positioned supine with the head fixated as for an MCA aneurysm (inset), with variable head rotation that depends on the craniotomy and AVM subtype. (b) The temporal craniotomy uses horseshoe-shaped scalp incision (green line) and a temporal craniotomy (red circle) extending to the floor of the middle fossa for subtemporal exposure (red-shaded rectangle). This approach is used with lateral, basal, and medial (posterior) AVMs. (c) The pterional craniotomy uses a semicircular scalp incision behind the hairline (green line) and a craniotomy centered on the pterion (red circle). This approach is used with lateral and sylvian AVMs. (d) The orbitozygomatic craniotomy combines the pterional craniotomy with removal of the orbit and zygoma for increased exposure of the medial temporal lobe. This approach is used with medial (anterior) AVMs. 图12.8 图解颞叶AVM手术路径。（a）颞叶AVM类型和交角（平行或垂直）。患者仰卧，像做MCA动脉瘤一样固定头部（头钉嵌入），依据入路和AVM类型旋转头部。（b）颞叶开颅采用马蹄形皮瓣（绿线），为了显露颞下（红色阴影矩形），骨瓣延至中颅窝底（红线圈）。外侧面型、底面型和内侧面型（后部）AVM可以用此入路。（c）翼点入路使用发际线后半圆形皮瓣（绿线）、以翼点（红色环）为中心开颅。适用于外侧面型和侧裂面型AVM。（d）眶颧入路将翼点入路联合磨除眶骨和颧弓以增加颞叶内侧的显露。主要用于颞叶内侧面型（前部）AVM。 Patients are positioned supine with 45 degrees of lateral head rotation for antero- lateral AVMs and 90 degrees of lateral head rotation for posterolateral AVMs. A “horse shoe” or “question mark” incision is used for temporal craniotomies, and a semicircular hairline incision is used for pterional craniotomies. Temporal craniotomies are centered over the EAC and typically extended inferiorly to the middle fossa floor. The dural opening is based on the pterion with pterional craniotomies, and inferiorly with temporal craniotomies (Fig. 12.9, step 1). Only sulcal dissection is needed to identify margins, cortical feeding arteries, and draining veins (step 2); sylvian fissure dissection is rarely or minimally needed. Drainage to the vein of Labbé is identified at the posterior margin, and drainage to the sylvian veins is identified superiorly (step 3). Superior feeding arteries are found along the temporal side of the sylvian fissure and traced to the AVM margin (step 4). Lateral temporal AVMs can have three arterial fronts: one superiorly from the MCA inferior trunk branches (MidTempA, PosTempA, and TempOccA) that are interrupted along the AVM’s superior margin near the STG; one anteriorly from the M1 MCA branches (TempPolA and ATA) that are interrupted pially along the anterior margin near the pole; and one inferiorly from the P2 PCA branches (PosTempA) that are interrupted along the inferior margin near the ITG (step 5). Parenchymal dissection proceeds with a circumferential and parallel attack (step 6). Awake anesthesia and intraoperative stimulation mapping may be indicated at this point in selected patients to localize speech function (a total of five patients in my experience). Deep dissection may extend to ependymal AVM in the temporal horn with AChA supply (step 7). The choroidal fissure can be opened in the horn medially and the AChA can be interrupted proximally (Figs. 12.10 and 12.11). 患者仰卧，前外侧AVM头侧旋45度，而后外侧AVM旋转90度。颞瓣开颅选用“马蹄”或“问号”形切口，翼点开颅则使用半圆形切口。颞瓣开颅以外耳道（EAC）为中心，标准做法是向下延伸到中颅窝底。以翼点入路方式切开硬膜，再以颞瓣开颅的方式向下延长切口（图12.9，步骤1）。为了辨别畸形团边界、皮层供血支和引流静脉，必须沿脑沟分离（步骤2）；不需或很少需要分离侧裂。在畸形团后缘要仔细辨别引流的Labbé静脉，以及向上引流到侧裂的静脉（步骤3）。颞叶外侧面型AVM的供血动脉来自三个方向：上方靠近颞上回（STG），沿AVM上缘阻断MCA下干的分支（MidTempA、PosTempA和TempOccA）；前方靠近颞极，在前缘阻断MCA的M1的分支（TempPolA和ATA）；下方靠近颞下回（ITG），在下缘阻断PCA的P2段分支（步骤5）。沿薄层分隔环形和平行操作分离（步骤6）。选取合适的病例做唤醒麻醉，使用术中刺激电图定位语言功能区（本组5例病例）。对于AChA供血位于下角的AVM，还要更深地解剖室管膜（步骤7）。在下角内侧打开脉络膜裂，靠近阻断AChA（图12.10和12.11）。 Fig. 12.9 Resection strategy for lateral temporal AVMs. (a) Step 1, exposing the AVM with a temporal craniotomy (surgeon’s view). (b) AVM box showing arterial inputs superiorly from MCA branches off the inferior trunk and inferiorly from PCA branches, with eloquence posteriorly (Wernicke’s area). 图12.9 颞叶外侧面型AVM的切除步骤。（a）步骤1，颞瓣开颅显露AVM（手术医生的视野）。（b）AVM箱显示来自上方MCA下干、下方PCA分支和后方语言区（Wernicke区）的供血。 Fig. 12.9 (continued) (c) Step 2, dissecting surface margins on the lateral temporal lobe; step 3, identifying draining convexity veins; step 4, identifying cortical MCA and PCA feeders; and step 5, interrupting the superior front along the STG and the inferior front along the ITG (surgeon’s view). (d) Step 6, circumdissecting into temporal parenchyma (coronal cross-sectional view). (e) Step 7, delivering the AVM from the temporal lobe. 图12.9（续）（c）步骤2，在颞叶外侧分离边界；步骤3，辨别皮层引流静脉；步骤4，辨别MCA和PCA的皮层支；步骤5，沿STG阻断上方、沿ITG阻断下方血供（手术医师视野）。（d）步骤6，在颞叶实质里环形分离（冠状切面观）。（e）步骤7，从颞叶移除AVM。 Fig. 12.10 This 30-year-old woman presented with a left lateral temporal AVM (supplemented Spetzler-Martin grade 6: S2V0E1/A2B1C0), fed by MidTempA and PosTempA, and drained by a large PosTempV, as seen on left ICA angiography [(a) lateral and (b) anteroposterior views]. (c) The lateral temporal surface was exposed through a large temporal craniotomy and speech areas were mapped with awake anesthesia (48 = Wernicke’s area, and 40 = Broca’s area). (d) By splitting the distal sylvian fissure, this compact AVM was separated from the frontal operculum. 图12.10 30岁女性，左侧颞叶外侧面型AVM（补充Spetzler-Martin分级6级：S2V0E1/A2B1C0），MidTempA和PosTempA供血，PosTempV引流，如同左侧ICA造影显示[（a）侧位和（b）正位]。（c）用一个大的颞瓣开颅显示颞叶外侧表面，在术中唤醒麻醉下标记语言区（48=Wernicke区，40=Broca区）。（d）通过分离侧裂远端，将致密的AVM从额顶岛盖分离下来。 Fig. 12.10 (continued) (e) Telfa strips and careful dissection protected speech areas, and MidTempA was skeletonized to occlude feedingarteries and preserve en passage arteries. (f) After AVM resection, the skeletonized MidTempA courses to distal territories supplying speech conduction pathways. The patient had no postoperative speech deficits. 图12.10（续）（e）棉片覆盖、仔细分离保护语言区，解剖MidTempA，阻断供血支，保护穿支动脉。（f）切除AVM后，骨架化的MidTempA向远处走行，供应语言传导束。患者无术后语言缺陷。
Fig. 12.11 This 20-year-old man presented with a left lateral temporal AVM (supplemented Spetzler-Martin grade 7: S3V0E1/A2B1C0) occupying most of the lateral surface, fed by the ATA, all branches of the inferior MCA trunk, the AChA, and PosTempA from the PCA, and drained by MidTempV. It was embolized preoperatively in three stages, with coils occluding large intranidal shunts (left ICA angiography [(a) lateral and (b) anteroposterior views]). (continued on next page) 图12.11 这是一个20岁的左颞叶外侧面型AVM（补充Spetzler-Martin分级7级：S3V0E1/A2B1C0），覆盖大部分外侧面，由ATA、所有MCA下干分支、AChA和来自PCA的POSTempA供血，MidTempV引流。术前分3期使用弹簧圈做畸形团内栓塞（左ICA造影）[(a)侧位（b）正位]（续下页）
Fig. 12.11 (continued) (c) A combined orbitozygomatic-temporal craniotomy exposed the entire AVM, including the temporal pole. (d) MidTempA was clipped proximal to the intraluminal coils and divided. (e) Temporal horn of lateral ventricle was entered through the superior temporal gyrus and the AChA identified in the choroidal fissure, where it was clipped, coagulated, and divided. (f) The anterior AVM margin was retracted posteriorly to dissect the ependymal surface of the temporal horn. The primary draining MidTempV coursing to the middle fossa floor was preserved throughout the dissection. 图12.11（续）（c）眶颧-颞叶联合入路显露整个AVM，包括颞极。（d）靠近血管内的弹簧圈阻断MidTempA，离断。（e）通过颞上回进入侧脑室颞角，在脉络裂里辨认AChA，阻断、电凝并离断。（f）向后牵开AVM前缘，分离颞角的室管膜平面。通过分离保护走行在中颅窝底的引流静脉MidTempV的起始部。 未完待续--- 原著作者: Michael T. Lawton, MD
编译者：杨海，華潤武鋼總醫院，神经外科，主任医师，硕士； |
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