Strategic neuronavigation-guided emergent endoscopic evacuation of the hematoma caused by ruptured brain arteriovenous malformation: Technical note and retrospective case series

Abstract

The treatment strategy for ruptured brain arteriovenous malformations (bAVMs) in the acute phase is still controversial. We describe five consecutive cases of successful emergent endoscopic evacuation (EEE) of intracerebral hematoma (ICH) caused by ruptured bAVMs with the electromagnetic (EM)-neuronavigation system to avoid damage to the bAVMs intended to save valuable time in the emergent phase. A single-institution retrospective analysis was performed in patients with ruptured bAVMs treated by the EM-navigated EEE as part of the strategic multimodality therapy. EM-navigated EEE was performed as follows: 1) obtaining three-dimensional computed tomography to identify the location of the nidus, large draining vein, feeding artery, and hematoma; 2) using a supine position without rigid head fixation for both supra- and infratentorial hematoma; 3) planning the entry point and trajectory of the endoscope as far as possible from the location of the nidus using the EM-navigation system; 4) designing a linear skin incision line suitable for the endoscopic surgery as well as possible decompressive craniectomy; and 5) performing EM-navigated endoscopic partial evacuation of ICH. EM-navigated EEE of ICH was successfully performed for all 5 patients, resulting in partial removal of the ICH without rebleeding from bAVMs. The mean surgical time was 37 min. Subsequent strategic endovascular embolization and curative resection of bAVMs could be performed for all patients, achieving Glasgow Coma Scale score of 15. EM-navigated EEE of partial ICH may be valuable in the emergent phase of ruptured bAVMs with massive life-threatening ICH to reduce the intracranial pressure and to obtain better prognosis.