Complications of angioma surgery--personal experience in 191 patients with cerebral angiomas

In the last years, treatment decisions of arteriovenous malformations (AVMs) were influenced by the improvement of stereotactic radiosurgery and were revolutionized by development of embolization techniques. The aim of this report was to examine the results, effectiveness, and complications associated with angioma surgery. 191 patients with AVMs were operated by the first author between 1981 and 1996. Angioma localization was distributed as follows: frontal 51 (26.7%), temporal 44 (23%), parietal 45 (23.6%), and occipital 24 (12.6%). Twelve (6.3%) AVMs were located in the cerebellum and 15 (7.9%) in other deep regions. Twenty-nine (15.2%) AVMs were associated with single or multiple aneurysms. The preoperative symptoms were hemorrhage (50.3%), seizure (33.5%), headache (23.0%), focal neurological deficits (12.6%), and other minor symptoms. In 9.9%, the disease remains preoperatively asymptomatic. Based on the Spetzler/Martin scale (S/M), 38 patients were grade I, 39 grade II, 52 grade III, 39 grade IV, and 23 grade V. The following severe complications were observed: postoperative hemorrhage in 13 (6.8%), infection in six (3.1%), infarction in two (1.0%), and death in three (1.6%). The risk for postoperative complications was related to the preoperative S/M grade of the AVM. Severe complications only occurred in AVM grades IV and V. In 62 patients with grade IV and V AVM, three patients died (4.8%) and 12 showed neurological deterioration (19.4%). Only 3/129 (2.3%) patients with grade I-III AVM deteriorated postoperatively. No severe complications were observed in preembolized and recently operated patients. Microsurgical management of cerebral AVMs seems to be a reasonably safe procedure especially in grade I-III AVMs, with a mortality of less than 2%. With enough experience and exact attention to detail, the experienced neurosurgeon can remove many of these AVMs with a minimum of risk to the affected patient. Although hemorrhage from an AVM can be disabling or deadly, the course in many nonoperated high-grade AVMs (S/M grades IV and V) can be quite benign, if compared with their surgical risk. This may justify conservative treatment or treatment with radiosurgery in some high-grade (S/M grades IV and V) angiomas, especially in elderly patients.