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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Microsurgery for cerebral arteriovenous malformation management: a Siberian experience
Alexei L Krivoshapkin1, Evstafy G Melidy
1Research Institute of Traumatology, Novosibirsk Neurosurgical Centre, Railway Hospital, Novosibirsk Medical University, Russia, krivoshapkin@online.nsk.su
Abstract:
Cerebral vascular malformations remain among the most difficult neurosurgical entities to treat. We report a retrospective study of the outcome in 95 consecutive patients with angiographically revealed arteriovenous malformations (AVMs). Fifty-four patients underwent microsurgical total AVM removal (group I). Forty-one patients who refused open surgery (group II) were managed either by endovascular embolisation (16 cases), radiosurgery (three) or followed up with medical treatment for their symptoms. In the first group pretreatment with the non-selective beta-blocker propranolol before surgery, the current neuronavigation techniques, intraoperative embolisation and AVM nidus colouring in high flow AVM were used for total microsurgical excision of the lesions. All AVM patients but one survived microsurgery. The mortality rate was 1.8% for group I. Six patients with grade IV-V AVM developed new temporal neurological symptoms following surgery. Four of them recovered completely in 3-6 weeks; two patients remained with mild persistent monoparesis and with homonymous hemianopsia postoperatively. In ten of 13 epileptic patients surgery produced a cure. No patient re-bled following surgery. No postoperative normal perfusion pressure breakthrough occurred. In the second group ten patients (24%) developed intracerebral haemorrhages, six of ten patients demonstrated progressive seizures. The mortality rate in group II totalled 17% over 6 years. Microsurgical management approaches must consider preoperative correction of impaired cerebral autoregulation, neuronavigation for preoperative planning and intraoperative orientation, intraoperative embolisation and dying of the nidus for large high-flow AVMs.
Insights
Microsurgery offers a safer and more effective treatment for arteriovenous malformations (AVMs) compared to other methods. This study found a significantly lower mortality rate and fewer complications in patients undergoing microsurgical AVM removal.
Area of Science:
- Neurosurgery
- Vascular Neurology
- Interventional Neuroradiology
Background:
- Cerebral vascular malformations, specifically arteriovenous malformations (AVMs), present significant challenges in neurosurgical treatment.
- Outcomes for AVMs vary depending on the management strategy employed.
Purpose of the Study:
- To compare the outcomes of microsurgical total AVM removal with non-surgical or less invasive treatments.
- To evaluate the safety and efficacy of advanced microsurgical techniques for AVMs.
Main Methods:
- Retrospective study of 95 patients with angiographically confirmed AVMs.
- Group I: 54 patients underwent microsurgical total AVM removal with preoperative propranolol, neuronavigation, and intraoperative embolization/nidus coloring.
- Group II: 41 patients managed with endovascular embolization, radiosurgery, or medical treatment.
Main Results:
- Microsurgery (Group I) had a 1.8% mortality rate with one death, and 6 patients experienced temporary neurological deficits.
- No re-bleeding or postoperative normal perfusion pressure breakthrough occurred in Group I.
- Non-surgical management (Group II) resulted in a 17% mortality rate over 6 years, with 24% experiencing intracerebral hemorrhages and progressive seizures.
Conclusions:
- Microsurgical AVM removal is associated with significantly lower mortality and morbidity compared to non-surgical options.
- Preoperative optimization of cerebral autoregulation, neuronavigation, and intraoperative adjuncts are crucial for successful microsurgical AVM excision.
