Acute surgical management of intracranial arteriovenous malformations

The majority of intracranial arteriovenous malformations (AVMs) do not require acute surgical intervention. Some patients, however, require emergent surgical treatment because of a profound neurological deterioration from a mass effect. We report 10 patients who underwent emergency AVM surgery after experiencing neurological deterioration from an intracranial hemorrhage. Two patients bled spontaneously, whereas eight had an intracranial hemorrhage secondary to an embolization procedure. When the patients demonstrated neurological deterioration, they were intubated, hyperventilated, and underwent osmotic diuresis. Barbiturate anesthesia was initiated, and surgery was performed within 30 minutes in most cases. The hematomas were evacuated, and an attempt was made to excise the AVMs at the same time. Postoperatively, intracranial pressure was monitored, and barbiturate coma was maintained until the intracranial pressure returned to normal. Cerebral perfusion pressure was maintained above 55 mm Hg. The operation was confined to evacuating the hematoma in two patients with inoperable AVMs. The other eight patients underwent concomitant total AVM resection. Because of the severity of neurological deterioration, one patient who bled spontaneously underwent surgery based only on a computed tomographic scan of the brain. Nine patients made a good-to-excellent recovery. One patient with a large motor-strip AVM remained hemiplegic. We conclude that in patients presenting with profound neurological deterioration after a spontaneous intracranial hemorrhage or one associated with an embolization procedure, prompt hematoma evacuation with simultaneous AVM excision as well as perioperative intracranial pressure control with mannitol and barbiturates can yield a good-to-excellent outcome.