Craniotomy and direct access microcatheterization for preoperative embolization of a complex, high grade intracranial arteriovenous malformation

Abstract The presence of an intracranial arteriovenous malformation has a dramatic impact on local circulatory dynamics. Treatment of some arteriovenous malformations can result in disastrous hyperemic states caused by redistribution of previously shunted blood. This report describes serial hemodynamic measurements of both cerebral blood flow and flow velocity in 3 patients during treatment for arteriovenous malformations. Measurements of cerebral blood flow were made by computed tomographic scan employing the stable xenon inhalation technique; flow velocity, including autoregulatory characteristics, was measured by transcranial Doppler ultrasonogram. Substantial hyperemia developed in one patient (Case 1) after resection and in another (Case 3) after embolization. Embolization resulted in restoration of normal regional cerebral blood flow in a patient who demonstrated hypoperfusion before treatment (Case 2). In Patient 1, postoperative hyperemia was associated with persistently elevated flow velocities, and may have been accompanied by hemispheric neurological deficits. Sequential hemodynamic measurements may predict patients at risk of perioperative complications, and may become useful clinical guidelines for the extent and timing of embolization and for the timing of surgery after intracranial hemorrhage or preoperative embolization procedures.

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Role of Multimodal Cerebral Oximetry Monitoring in the Anesthetic Management of a Patient With High-Grade Intracranial Arteriovenous Malformation

A & A Practice ◽

10.1213/xaa.0000000000001192 ◽

2020 ◽

Vol 14 (6) ◽

pp. e01192

Author(s):

Neeraja Ajayan ◽

Ajay Prasad Hrishi ◽

Vijetha Nagendra ◽

Manikandan Sethuraman

Keyword(s):

Arteriovenous Malformation ◽

Anesthetic Management ◽

Cerebral Oximetry ◽

High Grade ◽

Intracranial Arteriovenous Malformation

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Embolization of Arteriovenous Malformation

Interventional Neuroradiology ◽

10.1177/15910199040100s211 ◽

2004 ◽

Vol 10 (2_suppl) ◽

pp. 54-58 ◽

Cited By ~ 3

Author(s):

H. Nagashima ◽

K. Hongo ◽

S. Kobayashi ◽

T. Takamae ◽

H. Okudera ◽

...

Keyword(s):

Arteriovenous Malformation ◽

Removal Rate ◽

Postoperative Bleeding ◽

University Hospital ◽

Neurological Deficits ◽

Preoperative Embolization ◽

Surgical Removal ◽

High Grade ◽

Previously Treated ◽

Microsurgical Resection

Treatment options for cerebral arteriovenous malformation (AVM) are still controversial due to the recent result of stereotactic radiosurgery and the improved result of microsurgical resection. We investigated previously treated AVM cases and discussed the efficacy and safety of preoperative embolization especially for microsurgical resection of high-grade AVM in the Spetzler-Martin grading. Efficacy of preoperative embolization was evaluated based on 126 previously treated AVM cases at Shinshu University Hospital during the last 25 years. The safety of embolization was evaluated based on our previously-embolized 58 AVM cases (91 procedures) in the last 11 years after introduction of preoperative embolization for AVM. In all 126 cases, 82 were treated before introduction of embolization and 44 were treated after introduction of embolization. In 82 cases of the pre-embolization era, 63 lesions were removed totally in 63 AVMs (77%), partially resected in 11 (13%) and untreated in eight (10%). In 74 surgically removed cases, 11 (15%) cases showed severe intra/postoperative bleeding. In 44 cases of the embolization era, lesions were removed totally in 29 AVMs (66%), disappeared only with embolization in one (2%), disappeared with radiosurgery in seven (16%) and were untreated in five (11%). In 32 surgically removed cases, only one (2%) case showed severe intra/postoperative bleeding. In all 58 embolized cases, 44 were surgically removed, six were treated with radiosurgery, one was eliminated with embolization alone and six were partially obliterated and followed up for their location. In 91 procedures for 58 cases, two haemorrhagic and three ischemic complications occurred, three were transient and two remained having neurological deficits. The introduction of preoperative embolization improved the total removal rate and reduced the intra/postoperative bleeding rate in surgical removal of AVM. The total risk of embolization is low and well-designed preoperative embolization makes surgical resection safer even in high-grade AVM in the Spetzler-Martin grading.

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