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.

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.

Patients With Refractory Epilepsy Treated Using a Modified Multiple Subpial Transection Technique

Neurosurgery ◽  
2013 ◽  
Vol 72 (6) ◽  
pp. 890-898 ◽  
Author(s):  
Glennie Ntsambi-Eba ◽  
Géraldo Vaz ◽  
Marie-Agnès Docquier ◽  
Kenou van Rijckevorsel ◽  
Christian Raftopoulos
Keyword(s):  
Surgical Treatment ◽  
Clinical Outcome ◽  
Refractory Epilepsy ◽  
Neurological Deficits ◽  
Cortical Areas ◽  
Brodmann Areas ◽  
Seizure Rate ◽  
Epileptogenic Foci ◽  
Medically Refractory Epilepsy

Abstract BACKGROUND: Multiple subpial transection (MST) is a potential surgical treatment for patients with epileptogenic foci located in cortical areas with higher functions. As neurosurgical teams have become more experienced with MST, the original technique has adapted. OBJECTIVE: To report our 6-year experience with a modified MST technique. METHODS: The population included 62 consecutive patients with medically refractory epilepsy treated by MST, with a follow-up period ranging from 2 to 9 years. MST was performed on gyri under neuronavigation and guided by intraoperative electrocorticography. We performed radiating MST from a single cortical entry point. The MST technique was described according to the number of transections performed and the Brodmann areas (BAs) involved. Any MST-related complications were registered and followed up. Clinical outcome was described in terms of seizure suppression or reduction according to the Engel modified classification. RESULTS: Twelve patients underwent MST alone (MSTa), and 50 had MST with another procedure. The main MST sites were BA 4 (61%) and 3, 1, 2 (58%); in 22% of cases, MST was performed in BA 44, 22, 39, and 40. Permanent neurological deficits were observed in 4 (6.4%) patients; 2 minor deficits were MST related (3.2%). A reduction in the seizure rate of at least 50% was seen in 79% of patients (MSTa group, 75%), and 42% became seizure free (MSTa group, 33%). CONCLUSION: This study demonstrates the efficacy and low morbidity of radiating MST performed under neuronavigation and intraoperative electrocorticography.

scholarly journals Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes

2014 ◽  
Vol 14 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Matthew B. Potts ◽  
Sunil A. Sheth ◽  
Jonathan Louie ◽  
Matthew D. Smyth ◽  
Penny K. Sneed ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Target Volume ◽  
Neurological Deficits ◽  
Single Institution ◽  
Risks And Benefits ◽  
Scale Scores ◽  
Time Of Presentation

Object Stereotactic radiosurgery (SRS) is an established treatment modality for brain arteriovenous malformations (AVMs) in children, but the optimal treatment parameters and associated treatment-related complications are not fully understood. The authors present their single-institution experience of using SRS, at a relatively low marginal dose, to treat AVMs in children for nearly 20 years; they report angiographic outcomes, posttreatment hemorrhage rates, adverse treatment-related events, and functional outcomes. Methods The authors conducted a retrospective review of 2 cohorts of children (18 years of age or younger) with AVMs treated from 1991 to 1998 and from 2000 to 2010. Results A total of 80 patients with follow-up data after SRS were identified. Mean age at SRS was 12.7 years, and 56% of patients had hemorrhage at the time of presentation. Median target volume was 3.1 cm3 (range 0.09–62.3 cm3), and median prescription marginal dose used was 17.5 Gy (range 12–20 Gy). Angiograms acquired 3 years after treatment were available for 47% of patients; AVM obliteration was achieved in 52% of patients who received a dose of 18–20 Gy and in 16% who received less than 18 Gy. At 5 years after SRS, the cumulative incidence of hemorrhage was 25% (95% CI 16%–37%). No permanent neurological deficits occurred in patients who did not experience posttreatment hemorrhage. Overall, good functional outcomes (modified Rankin Scale Scores 0–2) were observed for 78% of patients; for 66% of patients, functional status improved or remained the same as before treatment. Conclusions A low marginal dose minimizes SRS-related neurological deficits but leads to low rates of obliteration and high rates of hemorrhage. To maximize AVM obliteration and minimize posttreatment hemorrhage, the authors recommend a prescription marginal dose of 18 Gy or more. In addition, SRS-related symptoms such as headache and seizures should be considered when discussing risks and benefits of SRS for treating AVMs in children.

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.

A 3-tier classification of cerebral arteriovenous malformations

2011 ◽  
Vol 114 (3) ◽  
pp. 842-849 ◽  
Author(s):  
Robert F. Spetzler ◽  
Francisco A. Ponce
Keyword(s):  
Surgical Outcomes ◽  
Arteriovenous Malformations ◽  
Neurological Deficits ◽  
Cerebral Arteriovenous Malformations ◽  
Pooled Data ◽  
Class A ◽  
Tier System ◽  
Class B ◽  
Class C

Object The authors propose a 3-tier classification for cerebral arteriovenous malformations (AVMs). The classification is based on the original 5-tier Spetzler-Martin grading system, and reflects the treatment paradigm for these lesions. The implications of this modification in the literature are explored. Methods Class A combines Grades I and II AVMs, Class B are Grade III AVMs, and Class C combines Grades IV and V AVMs. Recommended management is surgery for Class A AVMs, multimodality treatment for Class B, and observation for Class C, with exceptions to the latter including recurrent hemorrhages and progressive neurological deficits. To evaluate whether combining grades is warranted from the perspective of surgical outcomes, the 3-tier system was applied to 1476 patients from 7 surgical series in which results were stratified according to Spetzler-Martin grades. Results Pairwise comparisons of individual Spetzler-Martin grades in the series analyzed showed the fewest significant differences (p < 0.05) in outcomes between Grades I and II AVMs and between Grades IV and V AVMs. In the pooled data analysis, significant differences in outcomes were found between all grades except IV and V (p = 0.38), and the lowest relative risks were found between Grades I and II (1.066) and between Grades IV and V (1.095). Using the pooled data, the predictive accuracies for surgical outcomes of the 5-tier and 3-tier systems were equivalent (receiver operating characteristic curve area 0.711 and 0.713, respectively). Conclusions Combining Grades I and II AVMs and combining Grades IV and V AVMs is justified in part because the differences in surgical results between these respective pairs are small. The proposed 3-tier classification of AVMs offers simplification of the Spetzler-Martin system, provides a guide to treatment, and is predictive of outcome. The revised classification not only simplifies treatment recommendations; by placing patients into 3 as opposed to 5 groups, statistical power is markedly increased for series comparisons.

scholarly journals A Short Bout of High-intensity Exercise Alters Ipsilesional Motor Cortical Excitability Post-stroke

2019 ◽  
Author(s):  
Xin Li ◽  
Charalambos C. Charalambous ◽  
Darcy S. Reisman ◽  
Susanne M. Morton
Keyword(s):  
High Intensity ◽  
Acute Exercise ◽  
Cortical Excitability ◽  
Motor Evoked Potentials ◽  
High Intensity Exercise ◽  
Exercise Protocol ◽  
Post Stroke ◽  
Motor Cortical Excitability ◽  
Motor Cortical ◽  
Lactate Levels

AbstractBackgroundAcute exercise can increase motor cortical excitability and enhance motor learning in healthy individuals, an effect known as exercise priming. Whether it has the same effects in people with stroke is unclear.ObjectivesThe objective of this study was to investigate whether a short, clinically-feasible high-intensity exercise protocol can increase motor cortical excitability in non-exercised muscles of chronic stroke survivors.MethodsThirteen participants with chronic, unilateral stroke participated in two sessions, at least one week apart, in a crossover design. In each session, they underwent either high-intensity lower extremity exercise or quiet rest. Motor cortical excitability of the extensor carpi radialis muscles was measured bilaterally with transcranial magnetic stimulation before and immediately after either exercise or rest. Motor cortical excitability changes (post-exercise or rest measures normalized to pre-test measures) were compared between exercise vs. rest conditions.ResultsAll participants were able to reach the target high-intensity exercise level. Blood lactate levels increased significantly after exercise (p < 0.001, d = 2.85). Resting motor evoked potentials from the lesioned hemisphere increased after exercise compared to the rest condition (p = 0.046, d = 2.76), but this was not the case for the non-lesioned hemisphere (p = 0.406, d = 0.25).ConclusionsHigh-intensity exercise can increase lesioned hemisphere motor cortical excitability in a non-exercised muscle post-stroke. Our short and clinically-feasible exercise protocol shows promise as a potential priming method in stroke rehabilitation.

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