Resection Of Arteriovenous Malformations Research Articles

Kombinasi Dexmedetomidine – Sevoflurane 0,5 MAC pada Bedah Mikro Reseksi Malformasi Arteri-Vena

Arterio-venous malformation (AVM) is a rare case, particularly among young patients (<40 years old). Maintaining haemodynamic stability and anticipating massive haemorrhage during micro surgery resection of AVM are fundamental for an anaesthetist. Total Intra Venous Anesthesia using propofol is still popular to control intracranial pressure as it is easily titrated and fast acting agent (both in onset and duration). Moreover, general neuruologic evaluation soon after anesthesia terminated is an integral important component of microsurgery of brain MAV. In this case report: a 20-year-old woman suddenly lost her consciousness and left-sided motors strength. Brain angiographic revealed an AVM in right frontal lobe. Microsurgery of brain AVM resection was performed. After 5-minute-preoxygenation, anaesthetic induction was performed by using propofol, fentanyl, rocuronium, and sevoflurane. The surgery went successfully using a combination of dexmedetomidine-sevoflurane 0.5MAC. Post-anaesthesia hemodynamic of this patient was in stable and without new neurologic deficit afterward.

Retrospective Study and Outcome Predictor after Microsurgical Resection of Cerebral Arteriovenous Malformations in Nepal.

Objective:The purpose of this study is to assess demographic, clinical, and morphological characteristics of patients with brain arteriovenous malformations (bAVMs). The relation of outcome using modified Ranklin Scale (mRS) at time of discharge, early and last follow ups with respect to various factors.Materials and Methods:Demographic data, arteriovenous malformation characteristics, and treatment outcomes were evaluated in 43 bAVMs treated with microsurgery between 2009 and 2019. For this series, 43 patients were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades (SMG) I/II, III, IV/V and III–V were performed. The mRS was used to assess functional outcomes.Results:Overall, mean age at diagnosis was 33 years (standard deviation = 19). Transient deficit, mRS deterioration and impaired functional outcome occurred less frequently in SMG I–II patients compared with Grade III–V patients combined (29% vs. 32% respectively, P = 0.00). All patients with SMG Grade I, Supplemented SMG Grade 2, 3, 4 and 6 had a mRS score of 2 or less at the last follow-up. Age was the only significant predictor of overall outcome after bAVM surgery on Chi-square test (P = 0.046), i.e: all patients <20 years had mRS score of 2 or less on last follow-up. Unfavorable outcome (mRS score of 3 or more than 3) level increased with higher grades in SMG on long term follow-up.Conclusion:The results of our case series of bAVM with SMG Grade I and Suplemented Grade 2, 3, 4 and even higher grade i.e., 6 can have excellent overall outcome after microsurgical resection. Association of factors which increases the grading system of bAVM like eloquence, deep venous drainage and increasing sizes did not correlate with the predicted unfavorable outcomes, whereas age of patients was a predictor of overall outcome. Although the small sample size of this study is a limitation, age of patient plays important role on the overall outcome.

Multimodality treatment of supratentorial arteriovenous malformations with microsurgery after embolization: A retrospective two-center study in Vietnam

BackgroundPreoperative embolization with microsurgical resection has been used as a multimodality treatment of cerebral arteriovenous malformations (AVMs) in recent years. However, the role of this combined approach has not been well established. ObjectivesThis retrospective study aims to evaluate the outcomes of multimodality treatment with microsurgery after embolization for supratentorial AVMs in Vietnam. MethodsA two-center, retrospective case series of 26 patients with supratentorial AVMs who underwent treatment with surgical resection after embolization between January 2017 and August 2020 was performed. Sixty-three feeding arteries were embolized preoperatively in 29 sessions. We analyzed the AVM size, degree of preoperative obliteration, complications related to embolization, intraoperative blood loss, surgical complications, complete resection rate, and postoperative outcomes at 3 months after discharge. ResultsThe average size and Spetzler-Martin (SM) grade of AVMs were 4.98 cm (largest, 8 cm) and 3.19, respectively. The average preoperative volumetric obliteration was 55.38%. The intraoperative average blood loss was 573 ml. Complications related to embolization were post-embolization cerebral hemorrhage in 2 cases (7.69%), new-onset neurological deficits in 1 (3.38%). Surgical complications included death in 2 cases (7.69%) and new-onset neurological deficits in 5 (19.23%). At 3-month follow-up, four patients with new-onset neurological deficits had recovered completely or nearly completely. Complete resection of AVMs was confirmed by postoperative imaging modalities in 24/24 cases. Favorable outcome was achieved in 23 cases (88.46%). ConclusionMultimodality treatment with microsurgery after embolization is a relatively safe and effective method which can be considered for managing large and complex brain AVMs.

Mapping of the Language Cortex.

Awake craniotomy with intraoperative neurophysiological language mapping (INLM) is an established procedure for patients undergoing surgery to resection tumors in the language cortex area. INLM and continuous neurophysiological monitoring allow assessment of the language function, which is not possible under general anesthesia. INLM of the brain areas provides a helpful tool to the operating surgeon in reducing the risks associated with tumor resection in the motor and language cortex. We present a literature review and the technical method used for INLM by utilizing direct electrical cortical stimulation. We also report the usefulness of INLM for evaluation of the language function during resection of cortical tumors, epilepsy foci, and arteriovenous malformations (AVMs) located near language areas. First, the central sulcus is identified by sensory mapping, followed by the motor cortex's identification by direct electrical cortical stimulation (DECS). Neurological assessment of the patient is done by auditory and visual feedback. The patient is asked to repeat numbers, days, words, sentences, read words, and name pictures during cortical stimulation. DECS may cause a slurring or speech arrest. Electrocorticography (ECoG) is also performed during cortical stimulation to identify any after-discharges. Examination of the patient occurs immediately after surgery, and then 24 hours, one week, six months, and 12 months postoperatively. Bipolar DECS for motor mapping with ECoG can safely and reliably be utilized to identify essential language areas with minimizing permanent language deficits and maximizing the extent of tumor resection.

Microsurgical Resection of an Orbital Arteriovenous Malformation With Intraoperative Digital Subtraction Angiography.

Microsurgical Resection of an Orbital Arteriovenous Malformation With Intraoperative Digital Subtraction Angiography.

Spetzler-Martin Grade III Arteriovenous Malformations: A Multicenter Propensity-Adjusted Analysis of the Effects of Preoperative Embolization.

Spetzler-Martin (SM) grade III arteriovenous malformations (AVMs) are at the boundary of safe operability, and preoperative embolization may reduce surgical risks. To evaluate the benefits of preoperative AVM embolization by comparing neurological outcomes in patients with grade III AVMs treated with or without preoperative embolization. All microsurgically treated grade III AVMs were identified from 2011 to 2018 at 2 medical centers. Neurological outcomes, measured as final modified Rankin Scale scores (mRS) and changes in mRS from preoperative baseline to last follow-up evaluation, were compared in patients with and without preoperative embolization. Of the 102 patients with grade III AVMs who were treated microsurgically, 57 (56%) underwent preoperative embolization. Significant differences were found between the patients with and without embolization in AVM eloquence (74% vs 93%, P=.02), size≥3cm (47% vs 73%, P=.01), diffuseness (7% vs 22%, P=.04), and mean final mRS (1.1 vs 2.0, P=.005). Poor outcomes were more frequent in patients without embolization (38%) than with embolization (7%) (final mRS>2; P<.001). Propensity-adjusted analysis revealed AVM resection without embolization was a risk factor for poor outcome (mRS score>2; odds ratio, 4.2; 95% CI, 1.1-16; P=.03). Nonembolization of SM grade III AVMs is associated with an increased risk of poor neurological outcomes after microsurgical resection. Preoperative embolization of intermediate-grade AVMs selected because of large AVM size, surgical inaccessibility of feeding arteries, and high flow should be employed more often than anticipated, even in the context of increasing microsurgical experience with AVMs.

Surgical Resection of an Arteriovenous Malformation

Resection of a large arteriovenous malformation can be one of the most challenging surgical procedures in vascular anomalies. Although the problem of hemostasis draws the most attention, reducing the high recurrence rate after surgery is the true challenge. The technical principles of surgery are the same as for any other resection, but surgery must be guided by an understanding of the unique biology and anatomy of arteriovenous malformation.

Augmented Reality Fluorescence Imaging in Cerebrovascular Surgery: A Single-Center Experience with Thirty-Nine Cases

Several intraoperative imaging methods exist in cerebrovascular surgery to visualize and analyze the vascular anatomy flow. A new method based on multispectral fluorescence (MFL) imaging of indocyanine green (ICG) video angiography (VA) allows real-time, augmented reality (AR) visualization of blood flow superimposed on white-light microscopic images. We describe our single-center experience using MFL AR in cerebrovascular surgery. Case descriptions are provided of cerebrovascular surgery with intraoperative use of MFL AR images performed at our institution from June 2018 to April 2020. MFL superimposes the blood flow in real time on white-light microscopic images. We used MFL AR imaging as well as standard ICG-VA visualization and intraoperative digital subtraction angiography (DSA) as a control. A total of 39 cases (33 aneurysm clippings, 4 arteriovenous malformations, and 2 external carotid-internal carotid bypass surgeries), were performed using MFL technology-based AR visualization of ICG. MFL AR imaging and DSA showed a high correlation concerning aneurysm occlusion and vessel patency. In arteriovenous malformation resection surgery, MFL AR imaging facilitated early identification of the feeding arteries and draining veins. Because of increased sensitivity of MFL AR, a reduced dose of ICG could be used, allowing repeated intraoperative imaging. There were no postoperative complications, side effects, or technical problems related to the use of MFL AR imaging. MFL AR is an easy-to-use adjunct in cerebrovascular surgery and shows a high correlation with intraoperative DSA. No interruption of the surgery is necessary because MFL AR images of the blood flow are superimposed in real time on white-light microscopic images.

Combined Use of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Intraoperative Armamentarium for Arteriovenous Malformation Surgery

Safety and efficacy in surgical treatment of cerebral arteriovenous malformations (AVMs) are dictated by thorough understanding of angioarchitectural features, intraoperative identification of feeding vessels, and appreciation of surrounding eloquent areas. Our aim was to describe the preliminary results of combined application of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) in a consecutive surgical series of AVM. We pointed out the tool's efficacy in distinguishing feeding from bystander vessels and in identifying pattern of venous drainage. We examined its role as an adjunct for semiquantitative evaluation of the nidus inflow. We used combined CDUS and CEUS in patients surgically treated for cerebral AVMs. We adopted these techniques following a designed protocol to guide safer AVM resection as an adjunct to indocyanine green videoangiography. Intraoperative assessment by ultrasound was performed before, during, and following nidus resection. Four surgically treated cerebral AVMs availed of the ultrasound protocol. Postoperative conventional angiography showed complete resection of the AVMs. CDUS and CEUS proved to be valuable adjunctive tools to indocyanine green videoangiography and micro-Doppler in properly navigating and discerning vascular structures, especially vessel feeders from bystanders. The protocol allows us to identify flow direction, estimate blood velocity within the nidus, and appreciate flow modifications following temporary clipping. Ultimately, it allows us to evaluate the degree of nidus deafferentation, residual flow, restoration of venous drainage and absence of arteriovenous shunts. The CDUS and CEUS protocol is safe and repeatable and works as real-time imaging, further supporting complete surgical resection of AVMs.

Microsurgical resection of unruptured cerebellar arteriovenous malformation presenting with trigeminal neuralgia.

Cerebellar arteriovenous malformations (AVMs) represent 10%–15% of all intracranial AVMs and are associated with a greater risk for hemorrhagic presentation compared with supratentorial AVMs. When they reach the cerebellopontine angle cistern, neurovascular compression syndromes, including trigeminal neuralgia and hemifacial spasm, can occur. Due to the aggressive natural history of cerebellar AVM, an effective treatment strategy is required. In this video, the authors demonstrate the technical nuances of microsurgical resection of an unruptured cerebellar AVM in a 24-year-old female presenting with trigeminal neuralgia. The patient underwent right retrosigmoid craniotomy and complete resection of the AVM with resolution of trigeminal neuralgia.The video can be found here: https://youtu.be/6GmNjgFQwx8

Intraoperative application of a new-generation 3D IV-DSA technology in resection of a hemorrhagic cerebellar AVM.

Although intravenous digital subtraction angiography (IV-DSA), cone-beam CT, and rotational angiography are well-established technologies, using them in a single system in the hybrid operating room to acquire high-quality noninvasive 3D images is a recent development. This video demonstrates microsurgical excision of a ruptured cerebellar arteriovenous malformation (AVM) in a 66-year-old male followed by intraoperative IV-DSA acquisition using a new-generation system (Artis Icono). IV-DSA confirmed in real time that no residual remained following excision without the need to reposition the patient. To the best of the authors’ knowledge, this is the first surgical video to demonstrate the simplified workflow and application of this technology in neurovascular surgery.The video can be found here: https://youtu.be/bo5ya9DQQPw

Endoscopic-assisted parieto-occipital interhemispheric precuneal transtentorial approach for microsurgical resection of vermian arteriovenous malformation: operative video and technical nuances.

In this illustrative video, the authors demonstrate resection of a superior vermian arteriovenous malformation (AVM) using the endoscopic-assisted parieto-occipital interhemispheric precuneal transtentorial approach. Lateral positioning allows for gravity-assisted access to the interhemispheric fissure without retractors. The parieto-occipital trajectory is useful in patients who have a steep tentorial angle and avoids manipulation of the occipital lobe and visual cortex. In addition, the authors utilize an angled endoscope, which allows full inspection of the resection bed after AVM removal to visualize areas hidden from the microsurgical view to minimize the chance of residual disease in a deep corridor with multiple visual obstructions.The video can be found here: https://youtu.be/hk9nIIdtqbI

Usefulness of the middle cerebellar peduncle approach for microsurgical resection of lateral pontine arteriovenous malformation.

Surgical treatment of brainstem arteriovenous malformation (AVM) is challenging and associated with a higher risk of complications and a lower rate of gross-total resection. The authors present their experience with the surgical management of lateral pontine AVM using the middle cerebellar peduncle approach. All cases presented with neurological deficits that were caused by hemorrhage before surgery. In all cases, the AVM was not visualized on postoperative angiography, and there was no deterioration of neurological symptoms. In this video, the authors report the treatment results of one case and describe the technique with a review of the literature.The video can be found here: https://youtu.be/bFvEMtMnrKw

TRACTOGRAFÍA POR RESONANCIA MAGNÉTICA INTEGRADA A LA NEURONAVEGACIÓN EN LA PLANIFICACIÓN QUIRÚRGICA DE UNA MALFORMACIÓN ARTERIOVENOSA TEMPORAL EN EL HOSPITAL NACIONAL DOS DE MAYO. REPORTE DE CASO

Introduction: Complete resection of a cerebral arteriovenous malformation (AVM) eliminates the risk of bleeding1. Although AVMs that adjoin eloquent areas have been studied with functional neuroimaging or intraoperative mapping, 2 the usefulness of tractography has been limited to case reports or small series. Selecting the patient for surgery for an AVM close to an eloquent area is a challenge. 3 Clinical case: 33-year-old man with a clinical picture of epilepsy for 8 years controlled with carbamazepine. Two years ago, after suspension of treatment, the seizures reappeared, some of the auditory hallucinations "voices asking for help." Brain tomography (CT) showed a hyperdense lesion suggestive of AVM in the left temporal region, which was confirmed with magnetic resonance imaging (MRI) and cerebral angiography. The AVM was completely resected using the tractography integrated into the Neuronavigation. Conclusion: Magnetic resonance tractography integrated into the Neuronavigation allows to assess in real-time the proximity of the nidus of AVM to the arcuate fasciculus tract and the use of intraoperative fluorescein video angiography allows to assess vascularity in real-time. All of this makes it possible to perform total resection without causing injury to the eloquent area by avoiding compromising the fibers of the arcuate fasciculus tract. Keywords: Intracranial Arteriovenous Malformations, Neuronavigation, Fluoresceins (Source: MeSH NLM)

Reconstruction after Radical Resection of Arteriovenous Malformation of the Finger Using Sensate Free Radial Forearm Flap Transfer

Reconstruction after Radical Resection of Arteriovenous Malformation of the Finger Using Sensate Free Radial Forearm Flap Transfer

Indocyanine Green Videoangiography for Detecting Hyperemia of the Surrounding Brain as the Cause of Persistent Red Vein after Cerebral Arteriovenous Malformation Resection: A Case Report

Indocyanine Green Videoangiography for Detecting Hyperemia of the Surrounding Brain as the Cause of Persistent Red Vein after Cerebral Arteriovenous Malformation Resection: A Case Report

Microsurgical resection of high-flow cerebral arteriovenous malformations after recurrent stroke

Arteriovenous malformations (AVMs) are tangled lesions that may digress the blood flow particularly the high flow ones and microsurgical resection is challenging. The natural history of AVM is not completely understood and its management is controversial. Microsurgical resection of cerebral arteriovenous malformation is a challenging procedure, particularly for high-flow type. Embolization, microsurgery, or radiotherapy are treatment options. Preoperative planning to control the feeders, arachnoid dissection around the AVM for identification and control of all arterial feeders around the AVM surfaces, lastly control of draining vein is the principal of microsurgery. The goal of surgery is to remove the AVM completely to eliminate the risk of bleeding avoiding neurological deterioration. In this paper, we reviewed a case of high-flow cerebral AVM in recurrent bleeding with successful microsurgical resection.The patient in this case report significantly improved his neurological condition and demonstrated a good quality of life during long-term follow-up. The results of this study showed that the microsurgical removal of AVMs represents an efficient treatment with good clinical outcomes. In the future, more investigations of the factors that lead to AVM rupture are required for the advancement of effective medical procedures.

P.14 Transcranial Colour Duplex Reveals Haemodynamically Significant Venous Flow Alterations Following Resection of Arteriovenous Malformation of the Brain

BackgroundResection of a brain arteriovenous malformation (bAVM) can impose several post-operative challenges including post- operative haemorrhage (POH) [1]. The mechanism of such complications remains controversial although deliberately inducing hypotension has proven successful for POH prevention [2]. Daily non-invasive monitoring for patients may be useful in predicting POH. Transcranial color duplex (TCCD) and central aortic pressures (CAP) can be derived non-invasively providing pressure and haemodynamic measurements. These techniques may provide valuable insight into the process of vessel remodeling following bAVM resection.MethodsThis prospective study evaluated fifteen patients with bAVMs. CAP and TCCD were studied pre-operatively and then daily for up to 14 days post-operatively. CAP and TCCD parameters were compared with a group of normal volunteers and a control group of participants having craniotomies.ResultsThe post-operative venous changes were dramatic and have not been previously studied. In the early post-operative period there was a marked prominence of venous flow adjacent to the middle cerebral artery. The venous signals demonstrated significantly increased velocities and pulsatility. Furthermore, two of the patients with sustained increased venous prominence, velocity, and pulsatility suffered a POH. After the initial period of post-operative venous flow alteration, the venous parameters returned to normal values.ConclusionThese preliminary findings provide insight into vessel remodeling and elucidate the time frame for venous flow alterations after surgery. If confirmed in future validation studies, the period of increased venous velocity, pulsatility and prominence may correlate to the time at which patients are at risk of POH.

Staged Surgical Resection of Brain Arteriovenous Malformations

Staged treatment of brain arteriovenous malformations (AVMs) is sometimes necessary to minimize risks associated with sudden changes in cerebral hemodynamics. With the increasing availability and optimization of endovascular techniques, multiple surgical resections are rarely necessary, although, due to specific anatomic circumstances, some AVMs still require staged surgery. Here, we describe the largest reported series of staged surgical resections of brain AVMs. This is a retrospective review of surgically resected AVMs at a single institution from 1998-2018. Patients who underwent ≥2 resections within 1 year were reviewed. Only those in whom initial resection was terminated with intention for further resection were included in analysis. Twenty patients underwent deliberately staged resection from 1998-2018. Average age at treatment was 36.2 years (SD 16.5 years). Eleven patients (55%) were female, and 12 (60%) had left-sided AVMs. Median Spetzler-Martin grade was 4 (interquartile range [IQR]: 3-4). Average AVM nidus diameter was 5.0 cm (SD 1.7 cm). Seven patients (35%) presented with AVM rupture, and 12 (60%) presented with focal neurologic deficits without hemorrhage. Seventeen patients (85%) underwent preoperative embolization, median number of embolizations was 3 (IQR: 2-4). Three patients (15%) underwent preoperative radiosurgery. Median number of days between surgeries was 28 (IQR: 8-41 days). Perioperative course was complicated by hemorrhage in 3 patients (15%); 1 required decompressive hemicraniectomy prior to the second stage of surgery. Good functional outcome (defined as modified Rankin Scale score ≤2) was achieved in 14 patients (70%). Staged surgical resection of large and complex AVMs can be performed with good outcomes in carefully selected patients.

Surgical management of pediatric rolandic arteriovenous malformations: a single-center case series.

Pediatric rolandic arteriovenous malformations (AVMs) present a treatment challenge given the lifetime risk of hemorrhage, rehemorrhage, and associated long-term morbidity. Microsurgical resection has been recommended as the optimal treatment for AVMs in general, but there is no dedicated literature on the outcomes of resection of pediatric rolandic AVMs. Here, the study objective was to review the outcomes of microsurgical resection of pediatric rolandic AVMs in the modern era, together with the utilization of surgical adjuncts including navigation, intraoperative angiography, and neurophysiological monitoring. The authors performed a retrospective review of patients 18 years of age and younger with cerebral AVMs microsurgically treated between January 2000 and May 2016 at The Hospital for Sick Children. Only those patients with an AVM whose nidus was located within the rolandic region were analyzed. A descriptive analysis was performed to identify patient demographics, preoperative AVM characteristics, and postoperative obliteration rates and neurological complications. A total of 279 AVMs were evaluated in the study period. Twenty-three of these AVMs were rolandic, and the median age in the 11 microsurgically treated cases was 11 years (range 1-17 years). AVM hemorrhage was the most common presentation, occurring in 8 patients (73%). Lesions were either Spetzler-Martin grade II (n = 8, 73%) or grade III (n = 3, 27%). The postoperative obliteration rate of AVMs was 100%. The mean imaging follow-up duration was 33 months (range 5-164 months). There was no documented recurrence of an AVM during follow-up. One patient developed a transient postoperative hemiparesis, while another patient developed right fingertip hyperesthesia. Microsurgical resection of rolandic pediatric AVMs yields excellent AVM obliteration with minimal neurological morbidity in selected patients. The incorporation of surgical adjuncts, including neurophysiological monitoring and neuronavigation, allows accurate demarcation of functional cortex and enables effective resection.