Surgical Management Of Posterior Fossa Arteriovenous Malformations

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-189-ONS-201 ◽  
Author(s):  
John Sinclair ◽  
Michael E. Kelly ◽  
Gary K. Steinberg
Keyword(s):  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Cranial Nerves ◽  
Venous Drainage ◽  
Cerebellar Nuclei ◽  
Preoperative Embolization ◽  
Frameless Stereotaxy ◽  
Microsurgical Resection

Abstract Objective: Arteriovenous malformations (AVMs) involving the cerebellum and brainstem are relatively rare lesions that most often present clinically as a result of a hemorrhagic episode. Although these AVMs were once thought to have a more aggressive clinical course in comparison with supratentorial AVMs, recent autopsy data suggests that there may be little difference in hemorrhage rates between the two locations. Although current management of these lesions often involves preoperative embolization and stereotactic radiosurgery, surgical resection remains the treatment of choice, conferring immediate protection to the patient from the risk of future hemorrhage. Methods: Most symptomatic AVMs that involve the cerebellum and the pial or ependymal surfaces of the brainstem are candidates for surgical resection. Preoperative angiography and magnetic resonance imaging studies are critical to determine suitability for resection and choice of operative exposure. In addition to considering the location of the nidus, arterial supply, and predominant venous drainage, the surgical approach must also be selected with consideration of the small confines of the posterior fossa and eloquence of the brainstem, cranial nerves, and deep cerebellar nuclei. Results: Since the 1980s, progressive advances in preoperative embolization, frameless stereotaxy, and intraoperative electrophysiologic monitoring have significantly improved the number of posterior fossa AVMs amenable to microsurgical resection with minimal morbidity and mortality. Conclusion: Future improvements in endovascular technology and stereotactic radiosurgery will likely continue to increase the number of posterior fossa AVMs that can safely be removed and further improve the clinical outcomes associated with microsurgical resection.

Thalamic and Basal Ganglia Arteriovenous Malformations: Redefining “Inoperable”

2008 ◽  
Vol 63 (suppl_1) ◽  
pp. ONS63-ONS68 ◽  
Author(s):  
Edward A.M. Duckworth ◽  
Bradley Gross ◽  
H. Hunt Batjer
Keyword(s):  
Basal Ganglia ◽  
Natural History ◽  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Lesion Size ◽  
Small Lesion ◽  
History Of ◽  
Microsurgical Techniques

Abstract Deep Arteriovenous Malformations of the basal ganglia and thalamus have an aggressive natural history and present a therapeutic challenge. More often than not, these lesions are deemed “inoperable” and are treated expectantly or with stereotactic radiosurgery. In some cases, clinical details combined with an opportune route of access dictate surgical resection. History of hemorrhage, small lesion size, and deep venous drainage each add to the aggressive natural history of these malformations. Interestingly, these same factors can point toward surgery. We present a discussion of the microsurgical techniques involved in managing these lesions, with an emphasis on situations that allow these lesions to be approached surgically.

Recurrence of Cerebral Arteriovenous Malformations Following Resection in Adults

Neurosurgery ◽  
2015 ◽  
Vol 78 (4) ◽  
pp. 562-571 ◽  
Author(s):  
Alexander A. Ivanov ◽  
Ali Alaraj ◽  
Fady T. Charbel ◽  
Victor Aletich ◽  
Sepideh Amin-Hanjani
Keyword(s):  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Pediatric Population ◽  
Statistical Significance ◽  
Adult Population ◽  
Venous Drainage ◽  
Preoperative Embolization ◽  
Eligibility Criteria ◽  
Complete Surgical Resection

Abstract BACKGROUND: Complete surgical resection of arteriovenous malformations (AVMs), documented by postoperative angiography, is generally felt to represent cure, obviating the need for long-term follow-up imaging. Although AVM recurrence has been reported in the pediatric population, this phenomenon has only rarely been documented in adults. Recurrence after treatment solely with embolization, however, has been reported more frequently. Thus, patients undergoing multimodal therapy with surgery following preoperative embolization may also be at higher risk for recurrence. OBJECTIVE: To determine if preoperative embolization contributes to recurrences of AVMs after complete surgical resection. METHODS: A retrospective study of patients undergoing AVM resection was performed. Those with complete surgical AVM resection, confirmed by negative early postoperative cerebral angiography and with available follow-up angiographic imaging –6 months postoperatively were included. RESULTS: Two hundred three patients underwent AVM resection between 1995 and 2012. Seventy-two patients met eligibility criteria. There were 3 recurrences (4%). Deep venous drainage and diffuse type of AVM nidus were significantly associated with recurrence. Although preoperative embolization did not reach statistical significance as an independent risk factor, radiographic data supported its role in every case, with the site of recurrence correlating with deep regions of nidus previously obliterated by embolization. CONCLUSION: AVM recurrences in the adult population may have a multifactorial origin. Although deep venous drainage and diffuse nidus are clearly risk factors, preoperative embolization may also be a contributing factor with the potential for recurrence of unresected but embolized portions of the AVM. Follow-up angiography at 1 to 3 years appears to be warranted.

Microsurgical resection of a glioblastoma multiforme of the medulla oblongata with intraoperative subcortical stimulation and mapping

2019 ◽  
Vol 1 (2) ◽  
pp. V1
Author(s):  
Sima Sayyahmelli ◽  
Jian Ruan ◽  
Bryan Wheeler ◽  
Mustafa K. Başkaya
Keyword(s):  
Glioblastoma Multiforme ◽  
Surgical Resection ◽  
Medulla Oblongata ◽  
Cranial Nerves ◽  
The Body ◽  
Fine Motor ◽  
Surgical Video ◽  
Inferior Aspect ◽  
Hyperintense Signal ◽  
Microsurgical Resection

Primary glioblastoma multiforme tumors of the medulla oblongata are rare, especially in the adult population. Perhaps due to this rarity, we are not aware of any previous reports addressing the resection of these tumors or their clinical outcomes.In this surgical video, we present a 43-year-old man with a 1-month history of left-sided paresthesia. The paresthesia initiated in the left hand, along with weakness and reduced fine motor control, and then spread to the entire left side of the body. He had recent weight loss, imbalance, difficulty in swallowing, and hoarseness in his voice. He also had a diminished gag reflex, and significant atrophy of the right side of the tongue with an accompanying deviation of the uvula and fasciculations of the tongue. MRI showed an infiltrative expansile mass within the medulla with peripheral enhancement and central necrosis. In T2/FLAIR sequences, a hyperintense signal extended superiorly into the left inferior aspect of the pons and left inferior cerebellar peduncle and inferiorly into the upper cervical cord.The decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of this infiltrative expansile intrinsic mass in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials and monitoring of lower cranial nerves IX, X, XI, and XII. A gross-total resection of the enhancing portion of the tumor was performed, along with a subtotal resection of the nonenhancing portion. The surgery and postoperative course were uneventful. Histopathology revealed a grade IV astrocytoma. The patient received radiation therapy.In this surgical video, we demonstrate important steps for the microsurgical resection of this challenging glioblastoma multiforme of the medulla oblongata.The video can be found here: https://youtu.be/QHbOVxdxbeU.

scholarly journals Techniques of Onyx Embolization of Arteriovenous Malformation: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kathryn M Wagner ◽  
Visish M Srinivasan ◽  
Peter Kan
Keyword(s):  
Informed Consent ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Great Care ◽  
Endovascular Techniques ◽  
Definitive Therapy ◽  
Feeding Vessels ◽  
Multiple Feeding ◽  
Staged Treatment

Abstract Advances in endovascular techniques and tools have allowed for treatment of complex arteriovenous malformations (AVMs), which historically may have posed unacceptable risk for open surgical resection. Endovascular treatment may be employed as an adjunct to surgical resection or as definitive therapy. Improvements in embolization materials have made endovascular AVM treatment safer for patients and useful across a variety of lesions. While many techniques are employed for transarterial AVM embolization, the essential tenets apply to all procedures: (1) great care should be taken to cannulate only vessels directly supplying the lesion, and not en passage vessels, prior to injecting embolisate; (2) embolisate should travel into the nidus, but not into the draining veins; (3) embolistate reflux proximal to the microcatheter should be avoided. There are several techniques that accomplish these goals, including the plug and push method, or using a balloon to prevent embolisate reflux. We use controlled injection of liquid Onyx (Medtronic), with increasing pressure over multiple injections pushing the embolisate forward into the AVM. This is repeated in multiple feeding vessels to decrease or eliminate supply to the AVM. Here, we present a 36-yr-old female with a right parietal AVM discovered on workup of headaches. After informed consent was obtained, she underwent preoperative embolization using this technique prior to uncomplicated surgical resection. The video shows the endovascular Onyx embolization of multiple feeding vessels over staged treatment.

Characteristics of Brain Arteriovenous Malformations Presenting with Seizures without Acute or Remote Hemorrhage

2011 ◽  
Vol 24 (6) ◽  
pp. 886-888 ◽  
Author(s):  
P. Jiang ◽  
X. Lv ◽  
Z. Wu ◽  
Y. Li ◽  
C. Jiang ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Brain Arteriovenous Malformations ◽  
Male Sex

We report on the predictors of seizure presention in unruptured brain arteriovenous malformations (AVMs). Between 1999 and 2008, 302 consecutive patients with AVMs were referred to our institution for endovascular treatment. Seventy-four patients (24.5%) experienced seizures without hemorrhage before treatment. We tested for statistical associations between angioarchitectural characteristics and seizure presentation. When we compared the 74 patients with seizures without hemorrhage with the 228 patients who did not experience seizures initially (total of 302 patients), male sex, cortical AVM location, AVM size of more than 3 cm, superficial venous drainage and presence of varices in the venous drainage were statistically associated with seizures (P=0.016, P=0.002, P=0.022, P=0.005, and P=0.022, respectively). Posterior fossa and deep locations and coexisting aneurysms were statistically associated with no seizures. The angioarchitectural characteristics of AVM associated with seizure presentation include male sex, cortical AVM location, AVM size of more than 3 cm, superficial venous drainage and presence of varices in the venous drainage.

Radiosurgery as a microsurgical adjunct: outcomes after microsurgical resection of intracranial arteriovenous malformations previously treated with stereotactic radiosurgery

2021 ◽  
pp. 1-12
Author(s):  
Mark Bigder ◽  
Omar Choudhri ◽  
Mihir Gupta ◽  
Santosh Gummidipundi ◽  
Summer S. Han ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Perioperative Period ◽  
Low Grade ◽  
High Grade ◽  
Eligibility Criteria ◽  
Previously Treated ◽  
Microsurgical Resection ◽  
Cerebral Avms ◽  
Staged Treatment

OBJECTIVE Microsurgical resection of arteriovenous malformations (AVMs) can be aided by staged treatment consisting of stereotactic radiosurgery followed by resection in a delayed fashion. This approach is particularly useful for high Spetzler-Martin (SM) grade lesions because radiosurgery can reduce flow through the AVM, downgrade the SM rating, and induce histopathological changes that additively render the AVM more manageable for resection. The authors present their 28-year experience in managing AVMs with adjunctive radiosurgery followed by resection. METHODS The authors retrospectively reviewed records of patients treated for cerebral AVMs at their institution between January 1990 and August 2019. All patients who underwent stereotactic radiosurgery (with or without embolization), followed by resection, were included in the study. Of 1245 patients, 95 met the eligibility criteria. Univariate and multivariate regression analyses were performed to assess relationships between key variables and clinical outcomes. RESULTS The majority of lesions treated (53.9%) were high grade (SM grade IV–V), 31.5% were intermediate (SM grade III), and 16.6% were low grade (SM grade I–II). Hemorrhage was the initial presenting sign in half of all patients (49.5%). Complete resection was achieved among 84% of patients, whereas 16% had partial resection, the majority of whom received additional radiosurgery. Modified Rankin Scale (mRS) scores of 0–2 were achieved in 79.8% of patients, and 20.2% had poor (mRS scores 3–6) outcomes. Improved (44.8%) or stable (19%) mRS scores were observed among 63.8% of patients, whereas 36.2% had a decline in mRS scores. This includes 22 patients (23.4%) with AVM hemorrhage and 6 deaths (6.7%) outside the perioperative period but prior to AVM obliteration. CONCLUSIONS Stereotactic radiosurgery is a useful adjunct in the presurgical management of cerebral AVMs. Multimodal therapy allowed for high rates of AVM obliteration and acceptable morbidity rates, despite the predominance of high-grade lesions in this series of patients.

Curative treatment for low-grade arteriovenous malformations

2019 ◽  
Vol 12 (1) ◽  
pp. 48-54 ◽  
Author(s):  
Arthur Wang ◽  
Grace K Mandigo ◽  
Neil A Feldstein ◽  
Michael B Sisti ◽  
E Sander Connolly ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Curative Treatment ◽  
Embolic Agent ◽  
Preoperative Embolization ◽  
Low Grade ◽  
The Mean

BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.

scholarly journals Microsurgical resection of ambient cistern arteriovenous malformation

2016 ◽  
Vol 40 (videosuppl1) ◽  
pp. 1
Author(s):  
Omar Choudhri ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Posterior Cerebral Artery ◽  
Cranial Nerves ◽  
Superior Cerebellar Artery ◽  
Technical Aspects ◽  
The Third ◽  
Cerebellar Artery ◽  
Basal Vein Of Rosenthal ◽  
Microsurgical Resection ◽  
Ambient Cistern

The middle tentorial incisural space, located lateral to the midbrain and medial to the temporal lobe, contains the ambient cistern through which courses the third, fourth, and fifth cranial nerves, posterior cerebral artery (PCA), superior cerebellar artery, and the choroidal arteries. Arteriovenous malformations (AVMs) in this compartment are supplied by the thalamogeniculate and posterior temporal branches of the PCA, and drain into tributaries of the basal vein of Rosenthal. We present a case of an AVM in this middle tentorial incisural space that persisted after embolization and radiosurgery, and was microsurgically resected through a subtemporal approach. This case demonstrates the anatomy of the middle incisural space and technical aspects in microsurgical resection of these rare AVMs.The video can be found here: https://youtu.be/V-dIWh8ys3E.

Stereotactic radiosurgery for arteriovenous malformations of the cerebellum

2014 ◽  
Vol 120 (3) ◽  
pp. 583-590 ◽  
Author(s):  
Greg Bowden ◽  
Hideyuki Kano ◽  
Daniel Tonetti ◽  
Ajay Niranjan ◽  
John Flickinger ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Radiation Effects ◽  
Latency Period ◽  
Target Volume ◽  
Outcome Data ◽  
Cerebellar Malformations ◽  
Latency Interval ◽  
Permanent Neurological Deficit

Object Arteriovenous malformations (AVMs) of the posterior fossa have an aggressive natural history and propensity for hemorrhage. Although the cerebellum accounts for the majority of the posterior fossa volume, there is a paucity of stereotactic radiosurgery (SRS) outcome data for AVMs of this region. The authors sought to evaluate the long-term outcomes and risks of cerebellar AVM radiosurgery. Methods This single-institution retrospective analysis reviewed the authors' experience with Gamma Knife surgery during the period 1987–2007. During this time 64 patients (median age 47 years, range 8–75 years) underwent SRS for a cerebellar AVM. Forty-seven patients (73%) presented with an intracranial hemorrhage. The median target volume was 3.85 cm3 (range 0.2–12.5 cm3), and the median marginal dose was 21 Gy (range 15–25 Gy). Results Arteriovenous malformation obliteration was confirmed by MRI or angiography in 40 patients at a median follow-up of 73 months (range 4–255 months). The actuarial rates of total obliteration were 53% at 3 years, 69% at 4 years, and 76% at 5 and 10 years. Elevated obliteration rates were statistically higher in patients who underwent AVM SRS without prior embolization (p = 0.005). A smaller AVM volume was also associated with a higher rate of obliteration (p = 0.03). Four patients (6%) sustained a hemorrhage during the latency period and 3 died. The cumulative rates of AVM hemorrhage after SRS were 6% at 1, 5, and 10 years. This correlated with an overall annual hemorrhage rate of 2.0% during the latency interval. One patient experienced a hemorrhage 9 years after confirmed MRI and angiographic obliteration. A permanent neurological deficit due to adverse radiation effects developed in 1 patient (1.6%) and temporary complications were seen in 2 additional patients (3.1%). Conclusions Stereotactic radiosurgery proved to be most effective for patients with smaller and previously nonembolized cerebellar malformations. Hemorrhage during the latency period occurred at a rate of 2.0% per year until obliteration occurred.

scholarly journals Extended Anterolateral Infralabyrinthine Transjugular Approach for Microsurgical Resection of Giant Glomus Vagale Tumor: Operative Video and Technical Nuances

2020 ◽  
Author(s):  
James K. Liu ◽  
Kevin Zhao ◽  
Soly Baredes ◽  
Robert W. Jyung
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Jugular Foramen ◽  
Neck Mass ◽  
Preoperative Embolization ◽  
Rare Type ◽  
Lower Cranial Nerve ◽  
Microsurgical Resection ◽  
The Right ◽  
Lower Cranial Nerves

AbstractGlomus vagale tumor is a paraganglioma of the vagus nerve. It is a rare type of benign tumor that occupies the head and neck and skull base regions. Patients often present with lower cranial nerve dysfunctions such as difficulty swallowing, tongue weakness, and hoarseness. Surgical treatment can be complex and difficult due to its high vascularity, frequent involvement of lower cranial nerves, and surrounding critical vascular structures. In this operative video, we demonstrate an extended anterolateral infralabyrinthine transjugular approach for microsurgical resection of a giant glomus vagale tumor in a 53-year-old male who presented with an enlarging neck mass, difficulty swallowing, right tongue weakness, and hoarseness. Imaging revealed a giant glomus vagale tumor in the right parapharyngeal space extending into the jugular foramen with occlusion of the internal jugular vein. After preoperative embolization, the patient underwent a near-total resection of the tumor with a small microscopic residual at the pars nervosa. In summary, the extended anterolateral infralabyrinthine transjugular approach is a useful strategy for removal of giant glomus vagale tumors extending into the skull base. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/L0EosQK95LE.

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