Resection Of Malformation Research Articles

Surgical Hyperspectral imaging and Indocyanine green Near-infrared Examination (SHINE) for brain arteriovenous malformation resection: a case report on how to visualize perfusion

Background and importanceArteriovenous malformations (AVMs) are complex vascular anomalies that pose significant risks, including intracranial hemorrhage and neurological deficits. Surgical resection is the preferred treatment, requiring precise intraoperative imaging to ensure complete removal while preserving critical structures. This case report presents the first combined use of hyperspectral imaging (HSI) and indocyanine green video angiography (ICG VA) to visualize perfusion during brain AVM surgery, highlighting the potential benefits of these advanced imaging techniques.Case descriptionA 66-year-old male presented with chronic headaches but no neurological deficits. MRI revealed a superficial AVM in the left frontal lobe within the superior frontal sulcus, measuring approximately 2.4 cm. The AVM was fed by feeders from the pericallosal artery, callosomarginal artery, and middle cerebral artery (MCA) branches, with drainage through a dilated cortical vein into the superior sagittal sinus. Preoperative embolization of two MCA feeding branches was performed, followed by microsurgical resection with ICG VA and HSI.ConclusionsThis case report demonstrates the successful application of HSI and ICG VA in brain AVM surgery. The combined use of these technologies provided comprehensive intraoperative assessment, enhancing surgical precision and safety. The integration of HSI offers non-invasive, contrast-agent-free imaging, potentially improving outcomes by enabling detailed perfusion mapping. Future studies should explore the broader applications of these imaging modalities in neurovascular practice.

Timing of Embolization, Radiosurgery, and Resection of Arteriovenous Malformations in Pediatric Patients: A Retrospective, Descriptive Study

ObjectiveCerebral arteriovenous malformations (AVMs) are a challenging pathology in pediatric patients, carrying a high risk of morbidity and mortality. Treatment modalities include resection, endovascular embolization and stereotactic radiosurgery (SRS). There is currently no consensus favoring one modality over another. Timing of multimodal therapy with embolization/SRS and resection is not well explored in the literature. Here we present a series of pediatric AVM patients, with special attention paid to the timing of treatment. MethodsElectronic medical records of all pediatric patients (<18 years at treatment) with AVMs treated at our institution were retrospectively reviewed after IRB approval. Demographic information, AVM characteristics, treatment variables and outcomes were recorded. Results27 total patients were included. 21 (77.8%) presented with a ruptured AVM. 6 patients (28.6%) had an GCS of 3 to 10, and underwent treatment within 24 hours of presentation. 10 patients (47.6 %) with a GCS of 12 to 15 were treated between 24 to 120 hours. 5 patients (23.8%) were treated 3 weeks to 14 months after AVM rupture. 96% of our cohort, regardless of rupture status, had mRS of 1-2 at most recent follow-up. ConclusionsWe present our institution’s experience with pediatric AVM’s, focusing on the timing of treatment. Based on our experience, early treatment of AVMs seems to be safe and effective regardless of rupture status.

Microsurgical Resection of Calcified C2 Cavernous Malformation: 2-Dimensional Operative Video.

We present the case of a 58-year-old woman presenting with left upper limb paresthesia and bilateral lower limb spasm who was found to have a likely radiation-induced calcified intramedullary cavernous malformation at the level of C2.1-4 Owing to the symptomatic nature of the lesion with progressive increase in size and associated cord edema on serial imaging, through a lateral approach, the patient underwent a microsurgical left C2-3 hemilaminectomy and medial facetectomy to access the ventral exophytic calcified component.5-7 Debulking and piecemeal resection were performed with the aid of an ultrasonic bone aspirator with "claw" attachment while minimizing any manipulation of neural parenchyma.8-13 Ultimately, near total resection was achieved as a rim of capsule was left densely adherent to the spinal cord. Postoperatively, no new neurologic deficits were noted, and imaging as early as 1 week postoperatively showed significant reduction of cord signal abnormality. The technical considerations for the ultrasonic bone claw and the literature on treatment outcomes for calcified intramedullary spinal cavernous malformations are reviewed. The patient consented to the procedure and to the publication of her images. Institutional review board approval was deemed not necessary because of the retrospective, case report nature of this work.

Minipterional craniotomy for resection of epileptogenic cavernous malformation.

Epilepsy is a common symptom of pediatric cavernous malformations. In medically refractory patients, surgery can achieve high seizure freedom rates with low morbidity. This video depicts the use of a minipterional craniotomy and transsulcal resection of a frontal opercular cavernous malformation in a 13-year-old female with medically intractable epilepsy. At 1-year follow-up, she was evaluated as Engel class I with a significant improvement in her quality of life. Principles of cavernous malformation resection for the treatment of epilepsy are also reviewed. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2441.

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations

Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR). This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD. One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N= 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics. Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

Commentary: Microsurgical Resection of a Left Temporal Stem Cavernous Malformation via Transsylvian Approach: 2-Dimensional Operative Video.

Commentary: Microsurgical Resection of a Left Temporal Stem Cavernous Malformation via Transsylvian Approach: 2-Dimensional Operative Video.

WONOEP 2022: Neurotechnology for the diagnosis of epilepsy.

Epilepsy's myriad causes and clinical presentations ensure that accurate diagnoses and targeted treatments remain a challenge. Advanced neurotechnologies are needed to better characterize individual patients across multiple modalities and analytical techniques. At the XVIth Workshop on Neurobiology of Epilepsy: Early Onset Epilepsies: Neurobiology and Novel Therapeutic Strategies (WONOEP 2022), the session on "advanced tools" highlighted a range of approaches, from molecular phenotyping of genetic epilepsy models and resected tissue samples to imaging-guided localization of epileptogenic tissue for surgical resection of focal malformations. These tools integrate cutting edge research, clinical data acquisition, and advanced computational methods to leverage the rich information contained within increasingly large datasets. A number of common challenges and opportunities emerged, including the need for multidisciplinary collaboration, multimodal integration, potential ethical challenges, and the multistage path to clinical translation. Despite these challenges, advanced epilepsy neurotechnologies offer the potential to improve our understanding of the underlying causes of epilepsy and our capacity to provide patient-specific treatment.

Lost in transition? Loss of follow-up and quality of life in adults after resection of choledochal malformation in childhood.

Choledochal malformation (CM) is a rare disease that can lead to malignancy and potential long-term sequelae despite surgical resection. There is no long-term follow-up data on patients after CM resection in Germany. We aimed to determine the long-term outcome of our patients with a duration of follow-up >10 years and focused on long-term sequelae and health-related quality of life (HRQOL). All patients who had undergone CM-resection in our department from 01/1978 to 06/2009 were contacted. Patients were interviewed about postoperative complications and their present medical attendance. HRQOL was determined using Pediatric Quality of Life Inventory 4.0 (PedsQL), version for adults. The PedsQL scales the HRQOL from 0 to 100, with higher scores indicating a better HRQOL. Scores were compared to those published for a healthy population. Out of 56 patients who were contacted, 23 (41 %) participated. The median age at time of surgery was 3.1 years (6days-16.1 years) and at time of the survey 24.3 years (11.1-53.8 years). Eighteen patients (78 %) had ceased their gastroenterologic follow-up at a median time of 4.3 years after surgery. Five (22 %) were still in gastroenterologic follow-up, two of these had an uneventful clinical course, and three (13 %) had ongoing complications attributed to the CM. One of these had undergone hemihepatectomy 34 years postoperatively due to bile duct stenosis, one had undergone removal of bile duct stones 14 years postoperatively, and one suffered from portal vein thrombosis with esophageal and jejunal varices. There was no mortality in our series. Median total HRQOL score was 89. There was no significant difference in the median total health, physical health, and psychosocial health scores of our patients in comparison to the healthy population. We confirmed that the majority of patients after CM resection are lost to follow-up. Those who answered our questionnaire showed a good HRQOL. Given the high rate of severe long-term complications and the life-long risk of malignancy, we recommend a transition program for all patients.

Fully endoscopic approach for resection of brainstem cavernous malformations: a systematic review of the literature

BackgroundBrainstem cavernous malformations (BCMs) are benign lesions that typically have an acute onset and are associated with a high rate of morbidity. The selection of the optimal surgical approach is crucial for obtaining favorable outcomes, considering the different anatomical locations of various brainstem lesions. Endoscopic surgery is increasingly utilized in treating of BCMs, owing to its depth illumination and panoramic view capabilities. For intra-axial ventral BCMs, the best surgical options are endoscopic endonasal approaches, following the “two-point method. For cavernous hemangiomas on the dorsal side of the brainstem, endoscopy proves valuable by providing enhanced visualization of the operative field and minimizing the need for brain retraction.MethodsIn this review, we gathered data on the fully endoscopic approach for the resection of BCMs, and outlined technical notes and tips. Total of 15 articles were included in this review. The endoscopic endonasal approach was utilized in 19 patients, and the endoscopic transcranial approach was performed in 3 patients.ResultsThe overall resection rate was 81.8% (18/22). Among the 19 cases of endoscopic endonasal surgery, postoperative cerebrospinal fluid (CSF) leakage occurred in 5 cases, with lesions exceeding 2 cm in diameter in 3 patients with postoperative CSF rhinorrhea. Among the 20 patients with follow-up data, 2 showed no significant improvement after surgery, whereas the remaining 18 patients showed significant improvement compared to their admission symptoms.ConclusionsThis systematic literature review demonstrates that a fully endoscopic approach is a safe and effective option for the resection of BCMs. Further, it can be considered an alternative to conventional craniotomy, particularly when managed by a neurosurgical team with extensive experience in endoscopic surgery, addressing these challenging lesions.

Microsurgical removal of supratentorial and cerebellar cavernous malformations: what has changed? A single institution experience.

BackgroundFeatures associated with a safe surgical resection of cerebral cavernous malformations (CMs) are still not clear and what is needed to achieve this target has not been defined yet. MethodsClinical presentation, radiological features and anatomical locations were assessed for patients operated on from January 2008 to January 2018 for supratentorial and cerebellar cavernomas. Supratentorial CMs were divided into 3 subgroups (non-critical vs. superficial critical vs. deep critical). The clinical outcome was assessed through modified Rankin Scale (mRS) and was divided into favorable (mRS 0–1) and unfavorable (mRS ≥ 2). Post-operative epilepsy was classified according to the Maraire Scale. ResultsA total of 144 were considered eligible for the current study. At 6 months follow-up the clinical outcome was excellent for patients with cerebellar or lobar CMs in non-critical areas (mRS ≤ 1: 91.1 %) and for patients with superficial CMs in critical areas (mRS ≤ 1: 92.3 %). Patients with deep-seated suprantentorial CMs showed a favorable outcome in 76.9 %. As for epilepsy 58.5 % of patients presenting with a history of epilepsy were free from seizures and without therapy (Maraire grade I) at last follow-up (mean 3.9 years) and an additional 41.5 % had complete control of seizures with therapy (Maraire grade II). ConclusionsSurgery is safe in the management of CMs in non-critical but also in critical supratentorial locations, with a caveat for deep structures such as the insula, the basal ganglia and the thalamus/hypothalamus.

Microsurgical Resection of Brainstem Cavernous Malformations in Older Adults: A Multicenter, 30-Year Experience.

Microsurgical resection is the only curative intervention for symptomatic brainstem cavernous malformations (BSCMs), but the management of these lesions in older adults (≥65 years) is not well described. This study sought to address this gap by examining the safety and efficacy of BSCM resection in a cohort of older adults. Records of patients who underwent BSCM resection over a 30-year period were reviewed retrospectively. Baseline characteristics and outcomes were compared between older (≥65 years) and younger (<65 years) patients. Of 550 patients with BSCM who met inclusion criteria, 41 (7.5%) were older than 65 years. Midbrain (43.9% vs 26.1%) and medullary lesions (19.5% vs 13.6%) were more common in the older cohort than in the younger cohort ( P = .01). Components of the Lawton BSCM grading system (ie, lesion size, crossing axial midpoint, developmental venous anomaly, and timing of hemorrhage) were not significantly different between cohorts ( P ≥ .11). Mean (SD) Elixhauser comorbidity score was significantly higher in older patients (1.86 [1.06]) than in younger patients (0.66 [0.95]; P < .001). Older patients were significantly more likely than younger patients to have poor outcomes at final follow-up (28.9% vs 13.8%, P = .01; mean follow-up duration, 28.7 [39.1] months). However, regarding relative neurological outcome (preoperative modified Rankin Scale to final modified Rankin Scale), rate of worsening was not significantly different between older and younger patients (23.7% vs 14.9%, P = .15). BSCMs can be safely resected in older patients, and when each patient's unique health status and life expectancy are taken into account, these patients can have outcomes similar to younger patients.

Operative Volumes and Postoperative Outcomes After Elective Resection of Congenital Lung Malformations in Infants.

To determine whether hospital- and surgeon-level operative volumes are associated with differences in postoperative outcomes among infants undergoing elective lung surgery for a congenital lung malformation (CLM). Infant lung surgery is a relatively uncommon procedure performed by pediatric surgeons nationwide. The relationship between surgical volume and postoperative outcomes remains unknown. A retrospective cohort study of asymptomatic infants who underwent elective lung resection of a CLM was conducted using the Pediatric Health Information System database (2016-2020). Multivariable linear and poisson regressions were performed based on annual lung resection tertiles. There were 1420 infants managed by 48 hospitals and 309 primary surgeons. Institutions that performed seven or fewer CLM resections per year (56%) were associated with significantly higher postoperative complication rates compared to medium- and high-volume hospitals (low: 134 [34%], medium: 110 [21%], high: 144 [29%]; P<0.001). Surgeons who performed one or fewer CLM resections per year (82%) were associated with significantly higher complication rates compared to medium- and high-volume surgeons (low: 171 [31%], medium: 75 [26%], high: 119 [24%]; P=0.02). Multivariable analyses confirmed that low-volume hospitals were associated with higher complications (OR 1.81, CI 1.38-2.37; P<0.001), and low-volume surgeons had an increased risk of complications (overall: OR 1.37, CI 1.01-1.84; P=0.04). In this cohort study of infants undergoing elective lung resection for a CLM, lower volume providers were associated with higher postoperative patient morbidity. These findings represent an opportunity to inform quality improvement initiatives on pediatric lung resection and the debate on surgical subspecialization for this unique patient population.

Eloquent noneloquence: redefinition of cortical eloquence based on outcomes of superficial cerebral cavernous malformation resection.

Cerebral cavernous malformations (CMs) are pathological lesions that cause discrete cortical disruption with hemorrhage, and their transcortical resections can cause additional iatrogenic disruption. The analysis of microsurgically treated CMs might identify areas of "eloquent noneloquence," or cortex that is associated with unexpected deficits when injured or transgressed. Patients from a consecutive microsurgical series of superficial cerebral CMs who presented to the authors' center over a 13-year period were retrospectively analyzed. Neurological outcomes were measured using the modified Rankin Scale (mRS), and new, permanent neurological or cognitive symptoms not detected by changes in mRS scores were measured as additional functional decline. Patients with multiple lesions and surgical encounters for different lesions within the study interval were represented within the cohort as multiple patient entries. Virtual object models for CMs and approach trajectories to subcortical lesions were merged into a template brain model for subtyping and Quicktome connectomic analyses. Parcellation outputs from the models were analyzed for regional cerebral clustering. Overall, 362 CMs were resected in 346 patients, and convexity subtypes were the most common (132/362, 36.5%). Relative to the preoperative mRS score, 327 of 362 cases (90.3%) were in patients who improved or remained stable, 35 (9.7%) were in patients whose conditions worsened, and 47 (13.0%) were in patients who had additional functional decline. Machine learning analyses of lesion objects and trajectory cylinder mapping identified 7 hotspots of novel eloquence: supplementary motor area (bilateral), anterior cingulate cortex (bilateral), posterior cingulate cortex (bilateral), anterior insula (left), frontal pole (right), mesial temporal lobe (left), and occipital cortex (right). Transgyral and transsulcal resections that circumvent areas of traditional eloquence and navigate areas of presumed noneloquence may nonetheless result in unfavorable outcomes, demonstrating that brain long considered by neurosurgeons to be noneloquent may be eloquent. Eloquent hotspots within multiple large-scale networks redefine the neurosurgical concept of eloquence and call for more refined dissection techniques that maximize transsulcal dissection, intracapsular resection, and tissue preservation. Human connectomics, awareness of brain networks, and prioritization of cognitive outcomes require that we update our concept of cortical eloquence and incorporate this information into our surgical strategies.

Awake mapping for resection of cavernous angioma and arteriovenous malformations in the left dominant hemisphere

Awake mapping for resection of cavernous angioma and arteriovenous malformations in the left dominant hemisphere

Resection of Intracranial Giant Cavernous Malformation: Case Report and Literature Review

Resection of Intracranial Giant Cavernous Malformation: Case Report and Literature Review

Impact of selection criteria on the outcome of surgery following microsurgical resection of Intracranial Arterio-Venous Malformations (AVM)

Impact of selection criteria on the outcome of surgery following microsurgical resection of Intracranial Arterio-Venous Malformations (AVM)

Successful Surgical Resection of Pancreatic Arteriovenous Malformation Complicated by Acute Pancreatitis: A Case Report.

A 73-year-old man presented with left hypochondral pain. Dynamic computed tomography (CT) revealed abnormal vessels surrounding the pancreas, leading to a suspected diagnosis of pancreatic arteriovenous malformation (PAVM). At the time of the initial examination, dynamic CT revealed mild acute pancreatitis, and PAVM was diagnosed based on the findings of dynamic CT. Although repeated abdominal pain was observed after the improvement of pancreatitis, distal pancreatectomy was performed. At >1 year after surgery, no recurrence of PAVM was observed. Surgical resection should be considered in patients with symptomatic PAVM.

Updates on Neuronavigation: Emerging tools for tumor resection.

Multiple studies have been conducted to properly elucidate the various tools available to help enhance the resection of tumor tissue, aneurysms, and arteriovenous malformations (AVM). Diffusion tensor imaging (DTI) tractography is useful in providing a map of the tumor borders, allowing the optimal preservation of function and structure of specific regions of the brain. During neurosurgery, especially craniotomies, the possibility of the brain shifting due to swelling or gravity is high. Thus, tools for intraoperative imaging such as high-frequency linear array ultrasound transducers and doppler ultrasonography are utilized for high resolution images and detecting frequency shifts. 4D-digital subtraction angiography (DSA) is another technique used to create spatial resolutions and 3D maps for aneurysms. These similar techniques can also be utilized to assess the integrity of white matter in AVM. By implementing effective evaluation strategies, healthcare professionals can make informed decisions regarding treatment options, preventive measures, and long-term care plans tailored to individual patients.

Anatomical Variations and Anomalies of the Middle Cerebral Artery

Intracranial arteries have a high rate of variation, but a clear schematic overview is lacking. In this pictorial review we classify and depict all the variations and anomalies within the middle cerebral artery (MCA). PubMed was searched with the MeSH-term "Middle Cerebral Artery." Articles were selected based on their description of variants within the MCA. Cross-referencing was used to broaden the range of articles. The anatomical variants were then schematically drawn using the anteroposterior and lateral view during angiography of the internal carotid artery. A total of 29 unique medical illustrations were made, depicting variation in number of vessels; variation in vessel origin; and variation in morphology. The MCA provides vital blood supply to the frontal, parietal, temporal, and central brain structures. An overview of these variations is important to diagnose and treat patients with MCA-related pathology correctly and safely. They can aid in distinguishing pathology from normal anatomical variance; aid neurosurgeons during aneurysmal clipping or arteriovenous malformation resections; and aid interventional radiologists during thrombectomy or coiling. This article provides a summary regarding current knowledge of anatomical variations within the MCA, their prevalence and clinical relevance. A total of 29 unique illustrations were made, depicting currently known variants. We encourage all who diagnose, treat, and study the MCA to use this overview for a uniform and better understanding of its anatomy.

Dual Microscope Indocyanine Green Video Angiography and Endoscopic Review to Treat Intracranial Aneurysm: A Review of the Literature Regarding a Case.

The use of the indocyanine green video angiography (ICG-VA) both endoscope and microscope has become popular in recent decades thanks to the safety, efficacy, and added value that they have provided for cerebrovascular surgery. The dual use of these technologies is considered complementary and has helped cerebrovascular surgeons in decision-making, especially for aneurysm clipping surgery; however, its use has been described for both aneurysm surgery, resection of arteriovenous malformations, or even for bypass surgeries. We conducted a review of the literature with the MeSH terms "microscope indocyanine green video angiography (mICG-VA)," "endoscopic review," AND/OR "intracranial aneurysm." A total of 97 articles that included these terms were selected after a primary review to select a total of 26 articles for the final review. We also present a case to exemplify its use, in which we use both technological tools for the description of the aneurysm, as well as for decision-making at the time of clipping and for reclipping. Both tools, both the use of the endoscope and the mICG-VA, have helped decision-making in neurovascular surgery. A considerable clip replacement rate has been described with the use of these technologies, which has helped to reduce the complications associated with poor clipping. One of the main advantages of their usefulness is that they are tools for intraoperative use, which is why they have shown superiority compared to digital subtraction angiography, which takes longer to use and has a higher risk of complications associated with the contrast medium. On the other hand, a very low rate of complications has been described with the use of the endoscope and mICG-VA, which is why they are considered safe tools to use. In some cases, mention has been made of the use of one or the other technology; however, we consider that its dual use provides more information about the status of the clip, its anatomy, its relationship with other vascular structures, and the complete occlusion of the aneurysm. We consider that the use of both technologies is complementary, so in case of having them both should be used, since both the endoscope and the mICG-VA provide additional and useful information.