Abstract
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.
Highlights
The Spetzler-Martin Grading (SMG) system is widely used to evaluate therapeutic risks of brain arteriovenous malformations (AVMs) [1], and sorts AVMs into two classes: the low-grades (Grades I to III) and the high-grades (Grade IV and V)
The objective of this study is to introduce the experience of applying this paradigm to treat high-grade AVMs in one-staged hybrid operations, and its technical details which could potentially improve the functional outcome of the high-grades
Thirty-eight cases with AVMs in SMG IV and V met the inclusion and exclusion criteria and were involved in our study (Baseline information refers to Table 1)
Summary
The Spetzler-Martin Grading (SMG) system is widely used to evaluate therapeutic risks of brain arteriovenous malformations (AVMs) [1], and sorts AVMs into two classes: the low-grades (Grades I to III) and the high-grades (Grade IV and V). Binary and trinary multimodality therapeutic paradigms are proposed for the high-grades, consisting of microsurgical resection, endovascular intervention, and stereotactic radiosurgery (SRS). The multimodality paradigm, that consisted of endovascular embolization and subsequent stereotactic radiosurgery, could only achieve an obliteration rate ranging from 38 to 42% [15,16,17,18], and up to 44% by modifying SRS strategies [19]. Another multimodality paradigm consisted of volume-staged SRS and subsequent microsurgical resection was reported to achieve an obliteration rate of 93.8% [20]. All of the staged paradigms have to face the risks of adverse events in the latency period, especially the hemorrhagic risk, which ranges from 1.1 to 3.3% per year [16,17,18,19,20], and remains unchanged, as long as AVMs have not been completely obliterated
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