Superior outcomes in children compared with adults after microsurgical resection of brain arteriovenous malformations

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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RADIOSURGERY FACILITATES RESECTION OF BRAIN ARTERIOVENOUS MALFORMATIONS AND REDUCES SURGICAL MORBIDITY

Neurosurgery ◽

10.1227/01.neu.0000338068.44060.ea ◽

2009 ◽

Vol 64 (2) ◽

pp. 231-240 ◽

Cited By ~ 60

Author(s):

Rene O. Sanchez-Mejia ◽

Michael W. McDermott ◽

Jeffery Tan ◽

Helen Kim ◽

William L. Young ◽

...

Keyword(s):

San Francisco ◽

Arteriovenous Malformations ◽

Latency Period ◽

Preoperative Embolization ◽

Modified Rankin Scale ◽

Surgical Morbidity ◽

Operative Morbidity ◽

Brain Arteriovenous Malformations ◽

Asymptomatic Patients ◽

Microsurgical Resection

Abstract OBJECTIVE Stereotactic radiosurgery makes brain arteriovenous malformations (AVM) more manageable during their microsurgical resection. To better characterize these effects, we compared results of microsurgical resection of radiated (RS+) and nonradiated (RS−) AVMs to demonstrate that previous radiosurgery facilitates surgery and decreases operative morbidity. METHODS From our series of 344 patients who underwent AVM resections at the University of California, San Francisco (1997–2007), 21 RS+ patients were matched with 21 RS+ patients based on pretreatment clinical and AVM characteristics. Matching was blinded to outcomes, which were assessed with the modified Rankin Scale. RESULTS Mean AVM volume was reduced by 78% (P < 0.01), and Spetzler-Martin grades were reduced in 52% of RS+ patients (P < 0.001). Preoperative embolization was used less in RS+ than in RS− patients (P < 0.001). Mean operative time (P < 0.01), blood loss (P < 0.05), and length of hospital stay (P < 0.05) were lower in the RS+ group. Surgical morbidity was 14% higher in RS− patients, and they demonstrated significant worsening in modified Rankin Scale scores after surgery, whereas RS+ patients did not (P < 0.01). RS+ patients deteriorated between AVM diagnosis and surgery owing to hemorrhages during the latency period (P < 0.05). CONCLUSION Previous radiosurgery facilitates AVM microsurgery and decreases operative morbidity. Radiosurgery is recommended for unruptured AVMs that are not favorable for microsurgical resection. Microsurgical resection is recommended for radiated AVMs that are not completely obliterated after the 3-year latency period but are altered favorably for surgery, even in asymptomatic patients. Prompt resection of persistent AVMs should be considered to avoid the risk of postlatency hemorrhage and to optimize patient outcomes.

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