Surgical Treatment of Giant Intracranial Arteriovenous Malformations

Neurosurgery ◽  
2010 ◽  
Vol 67 (5) ◽  
pp. 1359-1370 ◽  
Author(s):  
Jizong Zhao ◽  
Tao Yu ◽  
Shuo Wang ◽  
Yuanli Zhao ◽  
Wu Yang Yang
Keyword(s):  
Surgical Treatment ◽  
Arteriovenous Malformations ◽  
Normal Function ◽  
Neurological Deficits ◽  
Grading System ◽  
Recurrence Rates ◽  
Presenting Symptoms ◽  
Good Outcome ◽  
Cranial Nerve Dysfunction ◽  
Cerebral Avms

Abstract BACKGROUND: The treatment of giant arteriovenous malformations (AVMs) remains a challenge in the neurosurgical field. Microsurgery is one of the most effective ways for eliminating giant cerebral AVMs. OBJECTIVE: To review surgical outcomes in treating the disease, and form conclusions regarding the indications for and outcomes of surgical treatment in giant intracranial AVMs. METHODS: We studied 40 consecutive cases of giant AVMs treated in Beijing Tiantan Hospital between 2000 and 2008. The radiologic and clinical features were analyzed. The Spetzler-Martin grading system was used to classify the patients. All patients were surgically treated, and the final outcomes of the patients were gathered for analysis. RESULTS: The major presenting symptoms were seizures, headaches, hemorrhage, and neurological deficits. The mean AVM diameter was 6.3 cm. According to the Spetzler-Martin grading system, 5 patients had grade III lesions, 21 had grade IV lesions, and 14 had grade V lesions. Out of the total 40 patients, 31 (77.5%) demonstrated excellent or good outcome. Complications included hemiparalysis, aphasia, hemianopia, cranial nerve dysfunction, and seizures. After follow-up, 27 of 30 (90%) surviving patients presented normal function or minimal symptoms. CONCLUSION: Presurgical evaluation of every candidate and treatment choice is the determining factor in therapy for giant AVMs. For giant cerebral AVMs located superficially or not involving critical components, a good outcome can be expected through surgical resection. The obliteration and recurrence rates were satisfying, and the complication rate was acceptable.

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

2015 ◽  
Vol 15 (1) ◽  
pp. 71-77 ◽  
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.

scholarly journals Preoperative silk suture embolization of cerebral and dural arteriovenous malformations

2001 ◽  
Vol 11 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Amir R. Dehdashti ◽  
Michel Muster ◽  
Alain Reverdin ◽  
Nicolas De Tribolet ◽  
Daniel A. Ruefenacht
Keyword(s):  
Arteriovenous Malformations ◽  
Histopathological Examination ◽  
Adverse Outcomes ◽  
Neurological Deficits ◽  
Grading System ◽  
Silk Suture ◽  
Long Term Follow Up ◽  
Feeding Vessels ◽  
A Minor ◽  
Proximal Occlusion

Object The aim of this study was to evaluate the use of silk sutures as a medical implant when applied for the embolization of cerebral and dural arteriovenous malformations (AVMs). The facility of surgery and the clinical significance of complications related to preoperative silk suture embolization were evaluated immediately after surgery and at long-term follow up. Methods Thirty-four patients harboring 29 cerebral and five dural AVMs underwent embolization in which silk alone or in association with other agents was used. Medical and radiological records obtained in these 34 patients were reviewed retrospectively. The cerebral AVMs were classified according to the Spetzler–Martin grading system and the dural AVMs to the Djindjian grading system. The facility of the resection and the adverse outcomes, including new neurological deficits, hemorrhage, and fever, as well as histopathological evidence of vessel inflammatory changes, were determined in each case. In all 23 surgical cases, the AVM could be easily manipulated and excised. New temporary neurological deficits occurred in three patients. A high Spetzler–Martin grade was not associated with a higher incidence of new neurological deficits. One delayed-onset hemorrhage was detected after embolization. Fever was present in 24% of the patients. No sign of significant vasculitis or perivascular inflammation was found on radiological or histopathological examination. Conclusions Silk sutures are safe embolic agents especially for proximal occlusion of AVM feeding vessels. New permanent neurological deficits were not encountered in this series. Fever was considered to be a minor, temporary side effect of silk suture embolization.

scholarly journals The influence of temporary occlusion of parent vessel on outcome of surgical treatment of ruptured cerebral aneurysms

2020 ◽  
Vol 77 (11) ◽  
pp. 1142-1145
Author(s):  
Vesna Nikolov ◽  
Misa Radisavljevic ◽  
Boban Jelenkovic ◽  
Marija Andjelkovic-Apostolovic
Keyword(s):  
Surgical Treatment ◽  
Cerebral Aneurysms ◽  
Aneurysm Rupture ◽  
Neurological Deficits ◽  
Grading System ◽  
Parent Vessel ◽  
Current Topic ◽  
Temporary Occlusion ◽  
A Prospective Study ◽  
Temporary Clipping

Background/Aim. Aneurysm rupture followed by sub-arachnoid or intracerebral haemorrhage is always current topic and poses a great challenge to neurosurgeons. The aim of the study was to establish whether applying temporary occlusion before placing a final clip was justified. Methods. A prospective study was conducted on patients with aneurysm rupture, treated at Neurosurgical Clinic in Nis from January 2012 to December 2016. Patients belonging to I and II and 1, 2 and 3 grades according to the Hunt-Hess grading system and Fisher scale, respectively, were monitored. Results. In 85, out of total 182 bleeding aneurysms that were treated, a neurosurgeon decided to apply temporary clipping before placing the final clip. Temporary occlusion significantly influenced the presence of resulting neuro-logical deficit. Conclusion. The application of temporary occlusion facilitates placing the final clip but also affects the occurrence of neurological deficits. It is assumed that this is a consequence of caused vasospasm, considering that these are bleeding aneurysms.

Safe Resection of Arteriovenous Malformations in Eloquent Motor Areas Aided by Functional Imaging and Intraoperative Monitoring

2011 ◽  
Vol 70 (suppl_2) ◽  
pp. ons276-ons289 ◽  
Author(s):  
Guilherme Lepski ◽  
Jürgen Honegger ◽  
Marina Liebsch ◽  
Marília Grando Sória ◽  
Porn Narischat ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Functional Imaging ◽  
Arteriovenous Malformations ◽  
Motor Evoked Potentials ◽  
Neurological Deficits ◽  
Functional Improvement ◽  
Cortical Areas ◽  
Electrophysiological Monitoring ◽  
Motor Cortical ◽  
Motor Areas

ABSTRACT BACKGROUND: Arteriovenous malformations (AVMs) proximal to motor cortical areas or motor projection systems are challenging to manage because of the risk of severe sensory and motor impairment. Surgical indication in these cases therefore remains controversial. OBJECTIVE: To propose a standardized approach for centrally situated AVMs based on functional imaging and intraoperative electrophysiological evaluation. METHODS: We conducted a retrospective analysis of 15 patients who underwent surgical treatment for AVMs in motor cortical areas or proximal to motor projections. Preoperative assessment included functional magnetic resonance and 3-dimensional tractography. Operations were performed under continuous electrophysiological monitoring aided by direct brain stimulation. We identified critical bloody supply to the motor areas by temporary occluding the feeding vessels under electrophysiological monitoring. Clinical outcome was evaluated with the modified Rankin Scale. RESULTS: Total resection was achieved in 12 cases, whereas electrophysiology limited total extirpation in 3 cases. A significant reduction of motor evoked potentials by up to 15% of the initial values was associated with good recovery of motor function; in contrast, the disappearance of potentials correlated with long-term impairment. The mean follow-up time was 13 months, and clinical assessments revealed overall functional improvement (P < .05). After surgery, 11 patients were asymptomatic or presented with only minor neurological deficits. CONCLUSION: Surgical resection of AVMs in eloquent motor areas can be considered a safe option for selected cases when performed in conjunction with a detailed functional assessment. Possible selection criteria for surgical treatment are discussed in light of the presented clinical data.

scholarly journals Angioarchitectural features amongst patients with unruptured brain arteriovenous malformations presenting with headache: findings from a single center retrospective review of 76 patients

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Benjamin N Africk ◽  
Daniel M Heiferman ◽  
Amy W Wozniak ◽  
Faraz Behzadi ◽  
Matthew S Ballard ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Medical Center ◽  
Neurological Deficits ◽  
Presenting Symptoms ◽  
Brain Arteriovenous Malformations ◽  
Diagnostic Codes ◽  
Venous Stenosis ◽  
Headache Management ◽  
Brain Avms ◽  
Arteries And Veins

Abstract Background Brain arteriovenous malformations (AVMs) consist of abnormal connections between arteries and veins via an interposing nidus. While hemorrhage is the most common presentation, unruptured AVMs can present with headaches, seizures, neurological deficits, or be found incidentally. It remains unclear as to what AVM characteristics contribute to pain generation amongst unruptured AVM patients with headaches. Methods To assess this relationship, the current study evaluates angiographic and clinical features amongst patients with unruptured brain AVMs presenting with headache. Loyola University Medical Center medical records were queried for diagnostic codes corresponding to AVMs. In patients with unruptured AVMs, we analyzed the correlation between the presenting symptom of headache and various demographic and angiographic features. Results Of the 144 AVMs treated at our institution between 1980 and 2017, 76 were unruptured and had sufficient clinical data available. Twenty-three presented with headaches, while 53 patients had other presenting symptoms. Patients presenting with headache were less likely to have venous stenosis compared to those with a non-headache presentation (13 % vs. 36 %, p = 0.044). Conclusions Our study suggests that the absence of venous stenosis may contribute to headache symptomatology. This serves as a basis for further study of correlations between AVM angioarchitecture and symptomatology to direct headache management in AVM patients.

Staged radiosurgery for extra-large cerebral arteriovenous malformations: method, implementation, and results

2008 ◽  
Vol 109 (Supplement) ◽  
pp. 65-72 ◽  
Author(s):  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Hsiu-Mei Wu ◽  
Kang-Du Liu ◽  
Wan-Yuo Guo ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Arteriovenous Malformations ◽  
High Signal ◽  
Minor Bleeding ◽  
Cerebral Arteriovenous Malformations ◽  
Presenting Symptoms ◽  
Second Stage ◽  
The Mean ◽  
Cerebral Avms

Object The effectiveness and safety of radiosurgery for small- to medium-sized cerebral arteriovenous malformations (AVMs) have been well established. However, the management for large cerebral AVMs remains a great challenge to neurosurgeons. In the past 5 years the authors performed preplanned staged radiosurgery to treat extra-large cerebral AVMs. Methods An extra-large cerebral AVM is defined as one with nidus volume > 40 ml. The nidus volume of cerebral AVM is measured from the dose plan—that is, as being the volume contained within the best-fit prescription isodose. From January 2003 to December 2007, the authors treated 6 patients with extra-large AVMs by preplanned staged GKS. Staged radiosurgery is implemented by rigid transformation with translation and rotation of coordinates between 2 stages. The average radiation-targeted volume was 60 ml (range 47–72 ml). The presenting symptoms were seizure in 4 patients and a bleeding episode in 2. One patient had undergone a previous craniotomy and evacuation of hematoma. The mean interval between the 2 radiosurgical sessions was 6.9 months (range 4.5–9.1 months). The prescribed marginal dose given to the nidus volume in each stage ranged from 16 to 18.6 Gy. The expected marginal dose of total nidus was 17–19 Gy. Regular follow-up MR imaging was performed every 6 months. The mean follow-up period was 28 months (range 12–54 months). Results Most of the patients exhibited clinical improvement: relief of headache and reduced frequency of seizure attack. All patients had significant regression of nidus observed on MR imaging follow-up. Two patients had angiogram-confirmed complete obliteration of the nidus 45 and 60 months after the second-stage radiosurgical session. One patient experienced minor bleeding 8 months after the second-stage radiosurgery with mild headache. She had satisfactory recovery without clinical neurological deficit after conservative treatment. Conclusions These preliminary results indicate that staged radiosurgery is a practical strategy to treat patients with extra-large cerebral AVMs. It takes longer to obliterate the AVMs. The observed high signal T2 changes after the radiosurgery appeared clinically insignificant in 6 patients followed up for an average of 28 months. Longer follow-up is necessary to confirm its long-term safety.

scholarly journals Neurological morbidity and mortality associated with the endovascular treatment of cerebral arteriovenous malformations before and during the Onyx era

2015 ◽  
Vol 122 (6) ◽  
pp. 1492-1497 ◽  
Author(s):  
R. Webster Crowley ◽  
Andrew F. Ducruet ◽  
M. Yashar S. Kalani ◽  
Louis J. Kim ◽  
Felipe C. Albuquerque ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Morbidity And Mortality ◽  
Neurological Deficits ◽  
Embolic Agent ◽  
Cerebral Arteriovenous Malformations ◽  
Neurological Morbidity ◽  
Martin Grade ◽  
The Mean ◽  
Cerebral Avms

OBJECT The widespread implementation of the embolic agent Onyx has changed the endovascular management of cerebral arteriovenous malformations (AVMs). Recent data suggest that outcomes following embolization and resection may have worsened in the Onyx era. It has been hypothesized that there may be increased complications with Onyx embolization and increased surgical aggressiveness in patients treated with Onyx. In this study the authors analyzed their institutional experience with the endovascular treatment of cerebral AVMs prior to and after the introduction of Onyx to determine factors associated with periprocedural neurological morbidity and mortality. METHODS A retrospective review was performed of all patients with cerebral AVMs undergoing embolization at the Barrow Neurological Institute from 1995 to 2012. RESULTS Endovascular treatment of 342 cerebral AVMs was performed over 446 treatment sessions (mean age 37.8 years, range 1–83 years). Clinical presentation included hemorrhage in 47.6%, seizures in 21.9%, headaches in 11.1%, and no symptoms in 10% of cases. The endovascular pretreatment strategy was preoperative in 78.9%, preradiosurgery in 9.1%, palliative in 5.3%, targeted in 4.4%, and curative in 2.3%. The median Spetzler-Martin grade was III. The mean number of arteries embolized was 3.5 (range 0–13 arteries), and the mean number of treatment sessions was 1.3 (range 1–4 sessions). Onyx was used in 105 AVMs (30.7%), and N-butyl cyanoacrylate (NBCA) without Onyx was used in 229 AVMs (67%). AVMs treated with Onyx had a higher mean number of arterial pedicles embolized than did NBCA cases (4.3 ± 2.7 vs 3.2 ± 2.4, respectively; p < 0.001) and a greater number of sessions (1.5 ± 0.7 vs 1.2 ± 0.5, respectively; p < 0.05). Unexpected immediate postprocedural permanent neurological deficits were present in 9.6% of AVMs, while transient deficits were present in 1.8%. There was 1 death (0.3%). Spetzler-Martin grade was not associated with differences in outcome, as permanent neurological deficits were observed in 12%, 9%, 13%, 11%, and 13% of AVMs for Spetzler-Martin Grades I–V, respectively (p = 0.91). The use of Onyx compared with NBCA was not associated with differences in periprocedural morbidity (p = 0.23). This lack of a difference persisted even when controlling for number of arteries and sessions (p = 0.14). Sex was not associated with differences in outcome. CONCLUSIONS Permanent and transient postprocedural neurological deficits were noted in 9.6% and 1.8% of all cases, respectively. AVM grade was not associated with endovascular outcome. Despite the greater number of sessions required and arteries embolized for Onyx cases, there was no statistically significant difference in the risk of neurological deficits following cerebral AVM embolization with Onyx and NBCA.

Delayed neurological deterioration following resection of arteriovenous malformations of the brain

1999 ◽  
Vol 90 (4) ◽  
pp. 695-701 ◽  
Author(s):  
Michael K. Morgan ◽  
Lali H. S. Sekhon ◽  
Simon Finfer ◽  
Verity Grinnell
Keyword(s):  
Arteriovenous Malformations ◽  
Cerebral Arteries ◽  
Venous Drainage ◽  
Neurological Deficits ◽  
Grading System ◽  
Content Type ◽  
Drainage Networks ◽  
Middle Cerebral Arteries ◽  
The Brain ◽  
Fine Print

Object. The aim of this study was to analyze delayed neurological deficits following surgical resection of arteriovenous malformations (AVMs).Methods. The authors report on a consecutive series of 200 patients with angiographically proven AVMs of the brain that were surgically resected between January 1989 and June 1998. The 30-day mortality rate for patients in this series was 1%, with one death caused by AVM resection and one death attributed to basilar artery aneurysm repair following successful AVM resection. The Spetzler—Martin grading system correlated well with the difficulty of surgery. No permanent incidence of morbidity resulted from resection of Grade I or II AVMs; the percentage of patients with a significant neurological deficit due to resection was 7.8% for those with Grade III lesions and 33.3% for those with Grade IV or V AVMs. However, this grading system did not accurately predict the development of delayed neurological deficits.Ten patients (5%) developed delayed neurological deficits after recovering from anesthesia and surgery. The delayed deficit was due to hemorrhage in four of the 10 patients and all four had undergone resection of AVMs measuring at least 4 cm in diameter. An increase in blood pressure during the first 8 postoperative days precipitated hemorrhage in these patients. Edema arising as a consequence of propagated venous thrombosis (two patients) was associated with extensive venous drainage networks rather than large AVM niduses. Both hemorrhagic and edematous complications can be included under the umbrella term of “arterial-capillary-venous hypertensive syndrome” to describe the common underlying pathogenesis accurately. An additional four patients developed a delayed deficit as a result of vasospasm. Vasospasm occurred when resection had involved extensive dissection of proximal anterior and middle cerebral arteries; in such cases the incidence of vasospasm was 27%.Conclusions. On the basis of their analysis of these complications, the authors recommend strict blood pressure control for patients with lesions measuring 4 cm or more in diameter (particularly those with a deep arterial supply). Thromboprophylaxis with aspirin and heparin is prescribed for patients with extensive venous drainage networks, and prophylactic nimodipine therapy and angiographic surveillance for vasospasm are suggested for patients in whom extensive dissection of proximal anterior or middle cerebral arteries has been necessary.

scholarly journals Spinal arteriovenous malformations: surgical outcome

2016 ◽  
Vol 11 (3) ◽  
Author(s):  
Khalid Mahmood ◽  
Afaq Sarwar ◽  
Anjum Habib Vohra
Keyword(s):  
Spinal Cord ◽  
Retrospective Study ◽  
Surgical Treatment ◽  
Arteriovenous Malformations ◽  
Spinal Angiography ◽  
Spinal Neoplasms ◽  
Feeding Vessels ◽  
Spinal Arteriovenous Malformations ◽  
Cerebral Avms ◽  
Set Up

Spinal arteriovenous malformations are relatively rare, being one tenth as common as cerebral AVMs and one tenth as common as primary spinal neoplasms. The aim of this retrospective study was to see distribution of this disease in spinal cord and analyse outcome of surgical treatment in our set-up. 5 patients with neurologic deficit due to spinal AVMs were operated upon from March 2000 to Feb 2005. Age ranged from 25-45 years with mean of 35 years. There were 2 females and 3 males with sex ratio of 1:1.5 respectively. Spinal AVMs were categorized as one of 4 types based on pattern of arterial and venous supply. We found that 60% (3 cases) in our series were intradural AVMs while 40% (2 cases) were dural type. We conclude that glomus variety of intradural AVMs was the commonest. The commonest presentation was acute spinal dysfunction and paraparesis. Selective spinal angiography can be negative in spinal AVMs, (20%) in our series, in which CT angiography provided clue to the feeding vessels.

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