Stereotactic craniotomy in the resection of small arteriovenous malformations

Surgical resection of 10 obscure arteriovenous malformations (AVM's) was accomplished with craniotomy guided by computerized tomography (CT) or angiography and the use of the Brown-Roberts-Wells stereotactic frame. Stereotactic craniotomy was invaluable for resection of the following types of AVM's: 1) AVM's with a nidus less than 2 cm in diameter, 2) AVM's located in an eloquent area of the brain, and 3) AVM's located deep in the brain. Stereotactic localization of these AVM's on preoperative radiological studies provides a precise route to the nidus, often avoiding important areas of the brain. This series included six male and four female patients with a mean age of 32 years. All patients presented with an intracerebral hemorrhage, from which eight made a complete neurological recovery prior to surgery. Two AVM's were located on the cortex, three were found subcortically, and five were situated near the ventricles or in the deep white matter. As a guide, angiography was used in six cases and CT in four cases. In each instance, the study providing the best image of the AVM nidus was employed. Postoperatively, no neurological deficits were found in eight patients and, in the two patients with preoperative deficits, neurological improvement was observed after recovery from surgery. Postoperative studies revealed complete removal of the AVM in all patients, and all lesions were confirmed histologically. The authors conclude that stereotactic craniotomy provides the optimum operative approach for the localization and microsurgical resection of AVM's that are either obscure or located deep in the brain.