Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula

Abstract BACKGROUND: Arteriovenous malformations (AVMs) in the basal ganglia, thalamus, and insula are considered inoperable given their depth, eloquence, and limited surgical exposure. Although many neurosurgeons opt for radiosurgery or observation, others have challenged the belief that deep AVMs are inoperable. Further discussion of patient selection, technique, and multimodality management is needed. OBJECTIVE: To describe and discuss the technical considerations of microsurgical resection for deep-seated AVMs. METHODS: Patients with deep AVMs who underwent surgery during a 14-year period were reviewed through the use of a prospective AVM registry. RESULTS: Microsurgery was performed in 48 patients with AVMs in the basal ganglia (n = 10), thalamus (n = 13), or insula (n = 25). The most common Spetzler-Martin grade was III− (68%). Surgical approaches included transsylvian (67%), transcallosal (19%), and transcortical (15%). Complete resection was achieved in 34 patients (71%), and patients with incomplete resection were treated with radiosurgery. Forty-five patients (94%) were improved or unchanged (mean follow-up, 1.6 years). CONCLUSION: This experience advances the notion that select deep AVMs may be operable lesions. Patients were highly selected for small size, hemorrhagic presentation, young age, and compactness—factors embodied in the Spetzler-Martin and Supplementary grading systems. Overall, 10 different approaches were used, exploiting direct, transcortical corridors created by hemorrhage or maximizing anatomic corridors through subarachnoid spaces and ventricles that minimize brain transgression. The same cautious attitude exercised in selecting patients for surgery was also exercised in deciding extent of resection, opting for incomplete resection and radiosurgery more than with other AVMs to prioritize neurological outcomes.

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Spetzler-Martin Grade III Arteriovenous Malformations: A Comparison of Modified and Supplemented Spetzler-Martin Grading Systems

Neurosurgery ◽

10.1093/neuros/nyab020 ◽

2021 ◽

Author(s):

Fabio A Frisoli ◽

Joshua S Catapano ◽

Dara S Farhadi ◽

Megan S Cadigan ◽

Candice L Nguyen ◽

...

Keyword(s):

Lower Risk ◽

Arteriovenous Malformations ◽

Predictive Power ◽

Preoperative Risk ◽

Factors Associated ◽

Neurological Outcomes ◽

Grading Systems ◽

Martin Grade ◽

Decision Making Tool ◽

Grade Iii

Abstract BACKGROUND The modified Spetzler-Martin (SM) grading system proposes that grade III arteriovenous malformation (AVM) subtypes are associated with variable microsurgical risks, with small AVMs (III−) having lower risk and medium/eloquent AVMs (III+) having higher risk. Adding patient age and AVM bleeding status and compactness to the SM grade produces a score – the supplemented SM (Supp-SM) grade – to more accurately assess preoperative risk. OBJECTIVE To compare the predictive power of the modified SM and Supp-SM grades for risk assessment in patients with grade III AVMs. METHODS Patients with SM grade III AVMs treated between 2011 and 2018 were retrospectively reviewed. Good outcomes were defined as modified Rankin Scale (mRS) scores ≤ 2 or unchanged/improved mRS scores (pre- vs postsurgery). RESULTS Of 102 patients with SM grade III AVMs, 59% had grade III− and 24% had grade III+ AVMs. Supp SM grade 6 and grade 7 AVMs accounted for 44% and 24%, respectively. Overall, 33% of patients worsened but outcomes did not significantly differ by SM III subtype. Neurological outcomes were associated with Supp-SM grade, with proportions of patients with worsening increasing from 0% with Supp-SM grade 4 AVMs to 54% with Supp-SM grade 7 AVMs. Analyses of factors associated with neurological worsening identified age > 60 yr and Supp-SM grade 7 as significant. CONCLUSION Supp-SM grades were more predictive of microsurgical outcomes than modified SM grades for grade III AVMs, with a hard cutoff for acceptable surgical risk at Supp-SM grade 6. Supp-SM grading is a better decision-making tool than subtyping with the modified SM scale.

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Microsurgery for cerebral arteriovenous malformations: subgroup outcomes in a consecutive series of 288 cases

Journal of Neurosurgery ◽

10.3171/2016.4.jns153017 ◽

2017 ◽

Vol 126 (4) ◽

pp. 1056-1063 ◽

Cited By ~ 29

Author(s):

Johannes Schramm ◽

Karl Schaller ◽

Jonas Esche ◽

Azize Boström

Keyword(s):

Arteriovenous Malformations ◽

Consecutive Series ◽

Cerebral Arteriovenous Malformations ◽

Class A ◽

Significant Deficit ◽

Microsurgical Resection ◽

Martin Grade ◽

Grade Iii

OBJECTIVE The objective of this study was to review the outcomes after microsurgical resection of cerebral arteriovenous malformations (AVMs) from a consecutive single-surgeon series. Clinical and imaging data were analyzed to address the following questions concerning AVM treatment in the post-ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) era. 1) Are the patients who present with unruptured or ruptured AVMs doing better at long-term follow-up? 2) Is the differentiation between Ponce Class A (Spetzler-Martin Grade I and II) patients versus Ponce Class B and C patients (Spetzler-Martin Grade III and IV) meaningful and applicable to surgical practice? 3) How did the ARUBA-eligible patients of this surgical series compare with the results reported in ARUBA? METHODS Two hundred eighty-eight patients with cerebral AVMs underwent microsurgical resection between 1983 and 2012 performed by the same surgeon (J.S.). This is a prospective case collection study that represents a consecutive series. The results are based on prospectively collected, early-outcome data that were supplemented by retrospectively collected, follow-up data for 94% of those cases. The analyzed data included the initial presentation, Spetzler-Martin grade, obliteration rates, surgical and neurological complications, and frequency of pretreatment with embolization or radiosurgery. The total cohort was compared using “small-AVM,” Spetzler-Martin Grade I and II, and ARUBA-eligible AVM subgroups. RESULTS The initial presentation was hemorrhage in 50.0% and seizures in 43.1% of patients. The series included 53 Spetzler-Martin Grade I (18.4%), 114 Spetzler-Martin Grade II (39.6%), 90 Spetzler-Martin Grade III (31.3%), 28 Spetzler-Martin Grade IV (9.7%), and 3 Spetzler-Martin Grade V (1.0%) AVMs. There were 144 unruptured and 104 ARUBA-eligible cases. Preembolization was used in 39 cases (13.5%). The occlusion rates for the total series and small AVM subgroup were 99% and 98.7%, respectively. The mean follow-up duration was 64 months. Early neurological deterioration was seen in 39.2% of patients, of which 12.2% had permanent and 5.6% had permanent significant deficits, and the mortality rate was 1.7% (n = 5). Outcome was better for patients with AVMs smaller than 3 cm (permanent deficit in 7.8% and permanent significant deficit in 3.2% of patients) and Ponce Class A status (permanent deficit in 7.8% and significant deficit in 3.2% of patients). Unruptured AVMs showed slightly higher new deficit rates (but 0 instances of mortality) among all cases, and in the small AVM and Ponce Class A subgroups. Unruptured Spetzler-Martin Grade I and II lesions had the best outcome (1.8% permanent significant deficit), and ARUBA-eligible Spetzler-Martin Grade I and II lesions had a slightly higher rate of permanent significant deficits (3.2%). CONCLUSIONS Microsurgery has a very high cure rate. Focusing microsurgical AVM resection on unruptured lesions smaller than 3 cm or on Spetzler-Martin Grade I and II lesions is a good strategy for minimizing long-term morbidity. Well-selected microsurgical cases lead to better outcomes than with multimodal interventions, as in the ARUBA treatment arm, or conservative treatment alone. Long-term prospective data collection is valuable.

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Surgical Management of Anterolateral and Posteromedial Incisural Tentorial Meningioma

Operative Neurosurgery ◽

10.1093/ons/opx228 ◽

2017 ◽

Vol 15 (2) ◽

pp. 120-130 ◽

Cited By ~ 2

Author(s):

Andrea Talacchi ◽

Antonio Biroli ◽

Stefano Medaglia ◽

Francesca Locatelli ◽

Mario Meglio

Keyword(s):

Residual Tumor ◽

Extent Of Resection ◽

Tumor Location ◽

Surgical Approaches ◽

Clinical Aspects ◽

Incomplete Resection ◽

Simpson Grade ◽

Tentorial Meningioma ◽

Deep Site

Abstract BACKGROUND Tentorial meningiomas are a broad and consistent category of tumors but their definition is still unclear and their classification uncertain. OBJECTIVE To report the clinical and surgical characteristics of tentorial hiatus meningiomas based on a revised classification of tentorial meningiomas. METHODS We reviewed the records of 14 patients who had undergone microsurgical removal of incisural tentorial meningioma. Two tumor subgroups, anterolateral (AL) and posteromedial (PM), were distinguished according to their site of attachment: the middle third and the posterior third of the tentorial free margin, respectively. Clinical presentation, radiological findings, surgical approaches, extent of resection, and outcome were compared. RESULTS The 2 subgroups differed by tumor size (larger in PM), incidence of the direction of growth (infratentorial in PM), and hydrocephalus (only in PM), as well as by some clinical aspects. Surgical approach depended on tumor location: lateral (pterional, subtemporal, and retromastoid) for AL lesions; medial (occipital or supracerebellar infratentorial) for PM lesions. Total removal (Simpson grade I-II) was performed in 64% of cases and complications occurred in 14%. Stereotactic radiosurgery was performed in cases of incomplete resection. At a mean follow-up of 104.5 mo, clinical improvement with low recurrence (9%) was achieved. CONCLUSION Reallocation of tentorial edge meningiomas is the premise to compare treatment and further improve the approach case-by-case. In spite of their deep site, good outcomes can be achieved in both AL and PM tentorial meningiomas. Also of note is the indolent behavior of residual tumor.

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Comparison of endoscope- versus microscope-assisted resection of deep-seated intracranial lesions using a minimally invasive port retractor system

Journal of Neurosurgery ◽

10.3171/2015.1.jns141113 ◽

2016 ◽

Vol 124 (3) ◽

pp. 799-810 ◽

Cited By ~ 18

Author(s):

Christopher S. Hong ◽

Daniel M. Prevedello ◽

J. Bradley Elder

Keyword(s):

Basal Ganglia ◽

Parietal Lobe ◽

Extent Of Resection ◽

Brain Lesions ◽

Neurological Injury ◽

Histopathological Diagnosis ◽

Incomplete Resection ◽

Complication Rates ◽

Tubular Retractor ◽

Technical Data

OBJECT Tubular brain retractors may improve access to deep-seated brain lesions while potentially reducing the risks of collateral neurological injury associated with standard microsurgical approaches. Here, microscope-assisted resection of lesions using tubular retractors is assessed to determine if it is superior to endoscope-assisted surgery due to the technological advancements associated with modern tubular ports and surgical microscopes. METHODS Following institutional approval of the tubular port, data obtained from the initial 20 patients to undergo transportal resection of deep-seated brain lesions were analyzed in this study. The pathological entities of the resected tissues included metastatic tumors (8 patients), glioma (7), meningioma (1), neurocytoma (1), radiation necrosis (1), primitive neuroectodermal tumor (1), and hemangioblastoma (1). Surgery incorporated endoscopic (5 patients) or microscopic (15) assistance. The locations included the basal ganglia (11 patients), cerebellum (4), frontal lobe (2), temporal lobe (2), and parietal lobe (1). Cases were reviewed for neurological outcomes, extent of resection (EOR), and complications. Technical data for the port, surgical microscope, and endoscope were analyzed. RESULTS EOR was considered total in 14 (70%), near total (> 95%) in 4 (20%), and subtotal (< 90%) in 2 (10%) of 20 patients. Incomplete resection was associated with the basal ganglia location (p < 0.05) and use of the endoscope (p < 0.002). Four of 5 (80%) endoscope-assisted cases were near-total (2) or subtotal (2) resection. Histopathological diagnosis, presenting neurological symptoms, and demographics were not associated with EOR. Complication rates were low and similar between groups. CONCLUSIONS Initial experience with tubular retractors favors use of the microscope rather than the endoscope due to a wider and 3D field of view. Improved microscope optics and tubular retractor design allows for binocular vision with improved lighting for the resection of deep-seated brain lesions.

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Effect of Presenting Hemorrhage on Outcome after Microsurgical Resection of Brain Arteriovenous Malformations

Neurosurgery ◽

10.1227/01.neu.0000153924.67360.ea ◽

2005 ◽

Vol 56 (3) ◽

pp. 485-493 ◽

Cited By ~ 115

Author(s):

Michael T. Lawton ◽

Rose Du ◽

Mary Nelson Tran ◽

Achal S. Achrol ◽

Charles E. McCulloch ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Predictor Variable ◽

Consecutive Series ◽

Surgical Morbidity ◽

Elective Resection ◽

Neurological Outcomes ◽

Improved Outcomes ◽

Increased Risk ◽

Microsurgical Resection

Abstract OBJECTIVE: We hypothesized that patients with unruptured arteriovenous malformations (AVMs) at presentation have an increased risk of deterioration compared with patients with ruptured AVMs. METHODS: A consecutive series of 224 patients treated microsurgically by a single neurosurgeon during a period of 6.4 years was analyzed. Initial hemorrhagic presentation was the primary predictor variable. Neurological outcomes were assessed by use of the Modified Rankin Scale (MRS) and Glasgow Outcome Scale (GOS), and logistic regression identified predictors of deterioration at follow-up (mean duration, 1.3 yr) relative to baseline before any intervention. RESULTS: Overall, 120 patients (54%) presented with hemorrhage, and all 224 patients underwent microsurgical resection. Complete resection was achieved in 220 patients (98%). According to GOS score, 13 patients (5.8%) deteriorated; according to MRS score, 45 patients (20.1%) deteriorated. Fifteen patients (6.7%) died. Hemorrhagic presentation was associated with improved outcomes, with a mean change in MRS score of +0.89 in patients with ruptured AVMs and −0.38 in patients with unruptured AVMs (P < 0.001). The final mean MRS scores in patients with unruptured AVMs were better than those in patients with ruptured AVMs (1.44 versus 1.90; P = 0.048). Presentation with an unruptured AVM was a predictor of worsening MRS score (odds ratio, 2.33; 95% confidence interval, 1.3–4.3; P = 0.006) but not of worsening GOS score. CONCLUSION: Presentation with AVM hemorrhage is an underappreciated predictor of outcome after therapy that includes microsurgical resection. Patients with ruptured AVMs tended to have deficits at presentation and generally improved after surgery, whereas patients with unruptured AVMs tended to have normal or nearly normal neurological function at presentation and were susceptible to worsening, albeit slight, as measured by MRS scores. Sensitive outcome measures such as MRS detect subtle symptoms and impairments missed by coarser measures such as GOS. Patients should be counseled that the risks associated with elective resection of unruptured AVMs may be higher than recognized previously. Hemorrhagic brain injury and its secondary effects may mask this surgical morbidity.

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Microsurgical treatment of arteriovenous malformations in pediatric patients: the Boston Children's Hospital experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2014.9.peds146 ◽

2015 ◽

Vol 15 (1) ◽

pp. 71-77 ◽

Cited By ~ 51

Author(s):

Bradley A. Gross ◽

Armide Storey ◽

Darren B. Orbach ◽

R. Michael Scott ◽

Edward R. Smith

Keyword(s):

Arteriovenous Malformations ◽

Neurological Complications ◽

Neurological Deficits ◽

Preoperative Embolization ◽

Recurrence Rates ◽

Microsurgical Treatment ◽

Obliteration Rate ◽

Microsurgical Resection ◽

Martin Grade ◽

Cerebral Avms

OBJECT Outcomes of microsurgical treatment of arteriovenous malformations (AVMs) in children are infrequently reported across large cohorts. METHODS The authors undertook a retrospective review of departmental and hospital databases to obtain the medical data of all patients up to 18 years of age who were diagnosed with cerebral AVMs. Demographic and AVM angioarchitectural characteristics were analyzed, and for the patients who underwent surgery, the authors also analyzed the estimated intraoperative blood loss, postoperative angiographically confirmed obliteration rates, and neurological complications and outcomes classified according to the modified Rankin Scale (mRS). RESULTS Of 117 children with cerebral AVMs, 94 underwent microsurgical resection (80%). Twenty (21%) of these 94 patients underwent adjunctive preoperative embolization. The overall postoperative angiographically confirmed obliteration rate was 94%. As part of a new protocol, the last 50 patients in this series underwent immediate perioperative angiography, improving the subsequent obliteration rate from 86% to 100% (p = 0.01). No other factors, such as a hemorrhagic AVM, size of the AVM, location, drainage, or Spetzler-Martin grade, had a statistically significant impact on the obliteration rate. Perioperative neurological deficits occurred in 17% of the patients, but the vast majority of these (77%) were predictable visual field cuts. Arteriovenous malformations that were hemorrhagic or located in noneloquent regions were each associated with lower rates of postoperative neurological complications (p = 0.05 and 0.002, respectively). In total, 94% of the children had good functional outcomes (mRS Scores 0–2), and these outcomes were significantly influenced by the mRS score on presentation before surgery (p = 0.01). A review of 1- and 5-year follow-up data indicated an overall annual hemorrhage rate of 0.3% and a recurrence rate of 0.9%. CONCLUSIONS Microsurgical resection of AVMs in children is associated with high rates of angiographically confirmed obliteration and low rates of significant neurological complications. Implementation of a protocol using perioperative angiography in this series led to complete radiographically confirmed obliteration of all AVMs, with low annual repeat hemorrhage and recurrence rates.

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Multimodal management of arteriovenous malformations of the basal ganglia and thalamus: factors affecting obliteration and outcome

Journal of Neurosurgery ◽

10.3171/2018.2.jns172511 ◽

2019 ◽

Vol 131 (2) ◽

pp. 410-419 ◽

Cited By ~ 1

Author(s):

Venkatesh S. Madhugiri ◽

Mario K. C. Teo ◽

Erick M. Westbroek ◽

Steven D. Chang ◽

Michael P. Marks ◽

...

Keyword(s):

Basal Ganglia ◽

Clinical Outcomes ◽

Arteriovenous Malformations ◽

Outcome Data ◽

Factors Affecting ◽

Complex Patients ◽

Martin Grade ◽

Improved Performance ◽

Multimodal Management

OBJECTIVEArteriovenous malformations (AVMs) of the basal ganglia and thalamus are particularly difficult lesions to treat, accounting for 3%–13% of all AVMs in surgical series and 23%–44% of malformations in radiosurgery series. The goal of this study was to report the results of multimodal management of basal ganglia and thalamic AVMs and investigate the factors that influence radiographic cure and good clinical outcomes.METHODSThis study was a retrospective analysis of a prospectively maintained database of all patients treated at the authors’ institution. Clinical, radiological, follow-up, and outcome data were analyzed. Univariate and multivariate analyses were conducted to explore the influence of various factors on outcome.RESULTSThe results and data analysis pertaining to 123 patients treated over 32 years are presented. In this cohort, radiographic cure was achieved in 50.9% of the patients. Seventy-five percent of patients had good clinical outcomes (stable or improved performance scores), whereas 25% worsened after treatment. Inclusion of surgery and radiosurgery independently predicted obliteration, whereas nidus diameter and volume predicted clinical outcomes. Nidus volume/diameter and inclusion of surgery predicted the optimal outcome, i.e., good clinical outcomes with lesion obliteration.CONCLUSIONSGood outcomes are possible with multimodal treatment in these complex patients. Increasing size and, by extension, higher Spetzler-Martin grade are associated with worse outcomes. Inclusion of multiple modalities of treatment as indicated could improve the chances of radiographic cure and good outcomes.

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THE EFFECTS OF DIFFUSENESS AND DEEP PERFORATING ARTERY SUPPLY ON OUTCOMES AFTER MICROSURGICAL RESECTION OF BRAIN ARTERIOVENOUS MALFORMATIONS

Neurosurgery ◽

10.1227/01.neu.0000255401.46151.8a ◽

2007 ◽

Vol 60 (4) ◽

pp. 638-648 ◽

Cited By ~ 69

Author(s):

Rose Du ◽

H. Michael Keyoung ◽

Christopher F. Dowd ◽

William L. Young ◽

Michael T. Lawton

Keyword(s):

Logistic Regression ◽

Regression Analysis ◽

Logistic Regression Analysis ◽

Arteriovenous Malformations ◽

Brain Parenchyma ◽

Consecutive Series ◽

Neurological Outcomes ◽

Perforating Artery ◽

Contour Plots ◽

Microsurgical Resection

Abstract OBJECTIVE Diffuse arteriovenous malformations (AVM) have non-compact niduses, irregular margins, and intervening brain parenchyma. Deep perforating arteries often contribute to the ragged border of these diffuse AVMs. We hypothesized that diffuseness and deep perforator supply increase the difficulties and risks associated with microsurgical AVM resection. METHODS Diffuseness was quantified using computer-generated outlines of AVMs on angiograms, contour plots with varying image intensities, and calculations of nidus area-intensity profiles. Diffuse AVMs had nonlinear area-intensity profiles with high transition intensities ([I*] greater than 0.5). A consecutive series of 304 patients who were treated with microsurgical AVM resection over a period of 7.8 years was analyzed, along with quantification of diffuseness in a subset of 103 consecutive patients. Neurological outcomes were assessed by using the Modified Rankin Scale, and logistic regression analysis was used to identify predictors of deterioration and poor outcome at late follow-up evaluation. RESULTS Diffuse niduses were observed in 25% of patients, and 18% of patients had deep perforating artery supply. Patients with compact AVMs were more likely to have good outcomes or overall improvement (88 and 87%, respectively) than patients with diffuse AVMs (65 and 54%, respectively) (P = 0.008 and P < 0.001, respectively). Similarly, absence of deep perforator supply was associated with good outcomes or improvement in 85 and 78% of patients, respectively, compared with 63 and 64% of patients, respectively, in patients with deep perforator supply (P < 0.001 and P = 0.028, respectively). By logistic regression analysis, diffuseness and deep perforator supply were both associated with significant increases in surgical risk. CONCLUSION Diffuseness and deep perforating artery supply are subtle features of an AVM that predict worse outcomes after microsurgical resection. Diffuseness makes surgical planes more difficult to determine and follow, whereas deep perforators are friable, poorly visualized, and located in eloquent white matter tracts. The Spetzler-Martin grading scale does not directly account for these two features; however, they should be considered carefully when making treatment recommendations to patients with AVMs.

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CHALLENGING TRADITIONAL BELIEFS

Neurosurgery ◽

10.1227/01.neu.0000316424.47673.03 ◽

2008 ◽

Vol 63 (3) ◽

pp. 393-411 ◽

Cited By ~ 29

Author(s):

Bradley A. Gross ◽

Edward A.M. Duckworth ◽

Christopher C. Getch ◽

Bernard R. Bendok ◽

H. Hunt Batjer

Keyword(s):

Basal Ganglia ◽

Mortality Rate ◽

Arteriovenous Malformations ◽

Creative Thinking ◽

Latency Period ◽

Surgical Approaches ◽

Preoperative Embolization ◽

Traditional Beliefs ◽

Complete Obliteration ◽

Surgical Corridor

ABSTRACT OBJECTIVE Arteriovenous malformations of the basal ganglia and thalamus are often managed with radiosurgery or observation, without consideration of microsurgery. Given the devastating effects of hemorrhage from these lesions, the accumulating evidence that they bleed more frequently than their lobar counterparts should prompt more creative thinking regarding their management. METHODS A review of the endovascular, microsurgical, and radiosurgical literature for arteriovenous malformations of the basal ganglia and thalamus was performed, with close attention to surgical approaches, obliteration rates, and procedure-related complications. RESULTS A complete resection rate of 91% and a mortality rate of 2.4% were found across surgical series of these lesions. These contrast with a 69% rate of complete obliteration and a 5.3% mortality rate (from latency-period hemorrhage) found when compiling results across the radiosurgical literature. CONCLUSION Given an appropriate surgical corridor of access, often afforded by incident hemorrhage, arteriovenous malformations of the basal ganglia and thalamus should be considered for microsurgical extirpation with preoperative embolization. In experienced hands, this approach presents an expeditious and definitive opportunity to eliminate the risk of subsequent hemorrhage and resultant morbidity and mortality.

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Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations

Frontiers in Neurology ◽

10.3389/fneur.2021.756307 ◽

2021 ◽

Vol 12 ◽

Author(s):

Mingze Wang ◽

Fa Lin ◽

Hancheng Qiu ◽

Yong Cao ◽

Shuo Wang ◽

...

Keyword(s):

Blood Loss ◽

Arteriovenous Malformations ◽

Endovascular Embolization ◽

Neurological Deficits ◽

High Grade ◽

Neurological Outcomes ◽

Brain Arteriovenous Malformations ◽

Hybrid Operation ◽

Microsurgical Resection ◽

The One

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

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