Surgical Treatment Of Arteriovenous Malformations Research Articles

Intraoperative selective cerebral angiography for microsurgical treatment of cerebral arteriovenous malformations in a hybrid operating room

Arteriovenous malformations (AVMs) of the brain are a congenital anomaly of the development of cerebral vessels, when instead of a normal capillary bed, a «network» of pathologically altered vessels is formed, through which arterial blood is shunted into the drainage venous system. Due to the thinned wall of the pathological vessels and high pressure in them, patients with AVMs are at risk of intracerebral hemorrhage up to 4 % annually, which determines the vital need for their treatment. Microsurgical removal of brain AVMs is considered the most radical and effective treatment method, the main goal of which is to completely disable the body of the malformation, since the remaining part can lead to the risk of postoperative bleeding. To ensure effective control over the completeness of AVM removal intraoperatively, two methods have been developed: selective cerebral angiography (SCAG) and indocyanine green video angiography (ICG-VA). According to the literature, SCAG provides a number of advantages in the intraoperative diagnosis of residual AVM parts compared to ICG-VA. The article analyzes our own experience in using intraoperative SCAG in the surgical treatment of AVM in a hybrid operating room and examines the literature data on the topic of the paper. Our study highlights the importance of using the method of intraoperative control through SCAG in order to improve the effectiveness of surgical treatment of cerebral AVMs.

Clinical case of successful surgical treatment of arteriovenous malformation of the thumb finger

The management of arteriovenous malformations of the hand is one of the most difficult problems in vascular surgery. It’s primarily related to the number of vessels and nerves involved in the pathological process on a very limited anatomical area. Commonly the required steps of the diagnostic process are the following: clinical examination, Doppler colour flow mapping, MRI with intravenous contrast, angiography and thermography. There are various methods ofsurgical treatment of patients with arteriovenous malformation of the hand. Generally, they might be classified as endovascular and open-surgical ones. Endovascular methods, such as embolization and sclerotherapy, are associated with the risk of severe complications such as soft tissue necrosis, distal vascular bed-specific thrombosis, along with both sensory and motor connectivity of the hand. However minimally invasive procedures do not always contribute to an appropriate clinical result. This article presents an example of successful surgical treatment of a patient with arterio-venous malformation of the thumb finger with severe pain syndrome and recurrent bleeding ulcers. A radical removal of the malformation-bearing tissue with preservation of the arterial blood supply was performed under an arterial tourniquet. At the one-year post-surgery follow-up examination, the patient noted the absence of pain syndrome and ulcers, restoration of mobility in the interphalangeal and metacarpophalangeal joints. Thus, the treatment of arteriovenous malformation of the hand should be based on the latest research findings and the most advanced testing technologies. This clinical case demonstrates that open surgery can be considered as an effective and sustainable clinical approach with a good medium-term outcome for the patients with arteriovenous malformation of the hand.

Surgical treatment of arteriovenous malformations of the buttock

For symptomatic buttock arteriovenous malformations (AVMs), embolization techniques and surgical resection have been suggested as treatment options. Our aim was to evaluate the feasibility and long-term results after a single surgical resection. Twelve patients had undergone surgical resection without preoperative embolization. Of the 12 patients, 11 had had incomplete procedures, 9 of whom had undergone arterial embolization 1 to 3years previously. All the patients were symptomatic. Computed tomography scans showed AVMs located in the cellular spaces with preservation of the gluteal muscle. The median follow-up time was 80months. On the last follow-up computed tomography scan, 67% had had no residual AVM. The use of preoperative embolization, especially with nonresorbable embolic material (Onyx; Medtronic, Dublin, Ireland), makes AVM resection and imaging follow-up more difficult because of artifacts and should be avoided.

Clinical example of surgical treatment of arteriovenous malformation in right thoracoscopic lobectomy

Pulmonary arteriovenous malformations are a rare congenital pathology observed in 2–3 individuals per 10,000, and 10 % of cases are diagnosed in children in the first several years of life. Arteriovenous malformations are vascular abnormalities of the cardiovascular system presenting as pathological anastomoses (shunts) between the arterial and venous systems which leads to direct shunting of nonoxygenated blood from the arterial bed into the venous bed bypassing pulmonary capillary network. Frequently, diagnosis of pulmonary arteriovenous malformations is made in rather neglected cases. Pulmonary arteriovenous malformations is hard to diagnose and treat, therefore it requires special attention from surgeons and clinicians which prompted us to describe a clinical case of a young 27-year old male patient with signs of significant chronic hypoxia (saturation (SpO2 ) – 84–86 %, hemoglobin level – 185 g/L, erythrocyte count – 6.13 million/μL, hematocrit – 51.8 %; during examination: acrocyanosis, nail clubbing; complaints of vertigo, decreased tolerance of physical activity, breathlessness during physical activity). Computed tomography in the S8, S9 segments showed arteriovenous malformation, size about 70 × 70 mm. Patient underwent radical treatment in the form of right lower thoracoscopic lobectomy which led to an immediate increase in oxygen saturation (SpO2 ) to 99 %. This clinical example shows that surgical method of treatment is the most radical, and thoracoscopic intervention in a young patient significantly decreases the volume of injury and promotes quick recovery and return to active life.

The efficacy of surgical treatment of cerebral arteriovenous malformations in a single academic institution: a case series

AimTo report on patients who underwent surgical treatment of arteriovenous malformations (AVMs) at our institution.MethodsThis retrospective single-center case series enrolled the patients who underwent surgical treatment of pial AVM at the Department of Neurosurgery, University Hospital Brno, between 2005 and 2019. The data are summarized as descriptive statistics presenting basic characteristics in all the patients and in sex or age subgroups.ResultsFifty patients were enrolled. The majority of AVMs were of Spetzler-Martin grade II (n = 27; 54%), localized supratentorialy (n = 43; 86%), and half of AVMs were ruptured. A total resection was performed in 48 patients (96%), and a good overall outcome was achieved in 44 patients (88%). Surgery-associated morbidity was 2%, and the mortality rate was 0% due to meticulous selection of patients for surgical treatment..ConclusionMicrosurgery is an appropriate method of treatment for S-M grade I-III pial AVMs. Microsurgery may be used to treat the majority of small-nidus AVMs with a low mortality and morbidity, when precisely planned and performed by an expert vascular team. The meticulous selection of patients for surgical treatment is crucial.

Clinical Staging, Angioarchitecture Type, and Surgical Treatment of Arteriovenous Malformations in the Head and Neck: A Single-Center Retrospective Analysis.

Head and neck are the predilection sites of arteriovenous malformations (AVMs). Although embolization is the first-line treatment for AVMs, complete surgical removal of the lesion still has its value due to the best outcome with low recurrence rate. Here, the authors made a retrospective analysis on the surgical treatment of AVMs in the head and neck. From January 2006 to December 2019, a total of 18 patients with AVMs in the head and neck were enrolled in this study, including 10 males. The Schobinger clinical staging, Yakes' angioarchitecture type, and surgical treatment were analyzed. The follow-up data were collected. Then, individual treatment strategies were summarized. According to Schobinger clinical classification system, 6 patients were at stage I, 7 patients at stage II, and 5 patients at stage III. According to Yakes' AVM classification system, 3 Type I, 4 Type II, 5 Type III, and 3 Type IV were confirmed. 3 patients cannot be confirmed due to lacking of arteriographic data. Surgical treatments included simple surgical excision (8 patients), dilator therapy (6 patients), and skin grafting after surgical excision (4 patients). In the follow-up period, 2 patients had recurrence and accepted operation again. All patients were satisfied with the appearance. Individual surgical treatment based on the clinical stage and angioarchitecture type can achieve satisfactory results in AVMs in the head and neck.

Combined surgical treatment of arteriovenous malformation of the lower jaw

The objective – to presents the observation of combined treatment of a patient with arteriovenous malformation of the lower jaw.A man, 21 years old, was hospitalized in the Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine with complaints of bleeding from a tooth socket after an attempt to remove the 6th tooth (first painter) of the lower jaw on the left. According to the performed survey radiography of the lower jaw, an aneurysmal bone cyst was revealed in the body of the lower jaw on the left, corresponding to the localization of bleeding. According to cerebral angiography, an arteriovenous malformation of the lower jaw was revealed on the left, the afferent arteries of which were: the right facial artery (a branch of the right external carotid artery (ECA)), the left facial artery (a branch of the left ECA), the lower alveolar artery, the superior-posterior alveolar artery (branches of the maxillary artery ‒ the terminal branch of the left ECA) with drainage into a vein, which was located in the body of the lower jaw. In order to exclude the malformation from the bloodstream and prevent bleeding, a controlled embolization of the malformation was performed using non-spherical emboli – polyvinyl alcohol (PVA) particles from Cook, USA. Using a transfemoral approach, a guide catheter was inserted into the orifice of the ECA, then a Headway 27 microcatheter (Microvention, USA) was passed through it along a Traxes 14 guide wire (Microvention, USA), the afferent arteries of the malformation were selectively cathete-rized in turn, and embolization was performed after superselective angiography. The patient was discharged in a satisfactory condition. Two weeks after the operation, the bleeding resumed. The performed control cerebral angiography revealed a relapse of the malformation with a change in its angioarchitectonics ‒ the filling of the malformation in the late arterial and venous phases of cerebral blood flow was noted. Re-embolization was performed using PVA emboli (Cook), which was supplemented by transcutaneous puncture of the drainage vein in the mandible and its embolization with histoacryl (B. Braun, Germany) and lipiodol (Guerbet, France) in a 1 : 1 ratio. Results. As a result of using this technique, it was possible to turn off the malformation completely. For 6 months from the moment of surgery, no bleeding was noted, and subsequently the patient had a tooth removed without complications.Conclusions. The proposed method for treating arteriovenous malformation of the lower jaw, proposed in this case, showed the effectiveness of a combination of endovascular embolization in combination with transcutaneous embolization of the draining vein and can be successfully used to treat this pathology.

Abstract TMP118: Clinical Outcomes of Surgical Resection After Stereotactic Radiosurgery Among Patients With Cerebral Arteriovenous Malformations

Introduction: Surgical treatment of arteriovenous malformations (AVMs), particularly higher grade lesions, can be aided by staged treatment consisting of stereotactic radiosurgery (SRS) followed by surgical resection in a delayed fashion. This strategy can be used to downgrade the AVM S-M grade, reduce blood flow through the AVM and often results in histopathological changes making AVMs more amenable to microsurgical resection. We present our 28-year clinical experience in managing AVMs with pre-operative SRS as a surgical adjunct. Methods: We retrospectively reviewed and analyzed records of all patients treated for cerebral AVMs between February 1991 and July 2019 at our institution. All patients that underwent SRS, with and without embolization, followed by microsurgery were included in the study. Of the 1245 cerebral AVM patients treated at our institution, 62 patients met eligibility criteria. Univariate and multivariate regression analysis was performed where appropriate to examine relationships between key variables and outcomes. Results: The majority of lesions (50%) were high grade (SM 4-5), 28.6% were intermediate (SM 3), while 21.4% were low grade (SM 1-2). Hemorrhage was the presenting sign among 22.6% of patients. Complete resection was achieved among 64.5%, 79% and 82% of patients after first, second and third surgical stages respectively; 16.1% of patients had partial resection requiring further treatment. Radiographic cure was achieved among 53 patients (85.5%), while 8 (12.9%) patients had residual AVM at last follow up. Six of 8 patients without radiographic cure received post-operative SRS. Thirty-seven patients (63.8%) had improved (26, 44.8%) or stable mRS scores (11, 19%), while 21 (36.2%) had a decline in mRS at final follow up compared to mRS at presentation; this includes 4 (6.9%) deaths due to hemorrhage, outside of the perioperative period, but occurring during follow up prior to AVM obliteration. Conclusion: SRS is a useful adjunct in the surgical management of cerebral AVMs. Multimodal therapy allowed for high obliteration rates with acceptable morbidity in this series of patients with predominantly high grade AVMs.

Evaluation of Qualitative Outcomes after Surgical Intervention on Patients Affected by Arteriovenous Malformations

Arteriovenous malformations are abnormal tangles of blood vessels that cause irregular connections between arteries and veins. Rupture of arteriovenous malformations represents a frequent complication associated with a neurological impairment and physical disability. We investigated the relationship among coping dimensions and overall quality of life (QoL), and health status after surgical intervention in 20 patients affected by arteriovenous malformations. Each patient was administered a battery of self-report questionnaires (Short Form 12 Health Survey Questionnaire, Brief COPE Inventory, Beck Depression Inventory, and Hamilton Rating Scale for Anxiety). We found that surgical treatment of arteriovenous malformations affected subjective well-being and emotional aspects. Coping ability influenced the QoL and the presence of anxiety and depressive symptoms. We found a significant correlation between depression and humor (r = -.47, P = .03) and between QoL and self-distraction (r = -.48, P = .03) and humor (r = .44, P = .05). In particular, humor was a significant predictor of mental health and physical health. The presence of anxiety and depression was the cause of deterioration of QoL, even if psychological resources used to deal with the disease significantly modified the subjective perception of well-being. The evaluation of the impact of cerebrovascular disease on QoL should be a basis for planning and evaluating therapeutic and psychological rehabilitative interventions.

Multimodal Treatment Strategy for Spetzler-Martin Grade III Arteriovenous Malformations of the Brain.

The Spetzler–Martin (S–M) grading scale was developed to assess the risk of postoperative neurological complications after the surgical treatment of arteriovenous malformations (AVMs) of the brain. Treatment-associated morbidity and poor outcomes are particularly relevant to Grade III AVMs and improving the safety while attaining acceptable cure rates still poses a challenge. A multimodal treatment strategy combining surgery, embolization, and radiosurgery is recommended for S–M Grade III AVMs because of the surgical risk. Grade III AVMs are the heterogeneous group that has been further divided into subgroups according to the size, the location in eloquent cortex, and the presence of deep venous drainage. The risks associated with different treatment modalities vary depending on the subgroup, and the rating scales have been further refined to predict the risk more accurately and help determine the most appropriate treatment choice. Previous results for the treatment of S–M Grade III AVMs vary widely among studies, and the treatment modalities are also different in each study. Being familiar with previous treatment results is essential for improving treatment outcomes.

Congenital Vascular Malformations with Arteriovenous Fistulae: Diagnosis and Treatment

Background: Arteriovenous malformations (AVMs) are congenital high flow vascular malformations (VMFs) composed of anomalous capillary beds shunting blood from the arterial system to the venous system. They are infiltrative causing destruction of the local tissue and often severe bleeding. Objectives: The aim of this study was to review the clinical results of surgical treatment for AVMs, with preoperative scleratherpy. Patients and methods: 24 patients with AVMs and AVFs were treated in a period from October 2012 to March 2015. All patients were subjected to history taking, clinical examination, laboratory investigations and imaging studies which included: colored Duplex ultrasound, CTA, arteriography and direct haemangiography. All patients were treated by surgical excision after preoperative injections of sclerotherapy. Results: Age incidence of the patients ranged between 1-35 years, 70.8% of them were below the age of 5 years and 80% of the patients were females. The common site for AVMs was the head and neck in 66.67%. Symptoms and sings included: cosmetic 83.33%, thrill and pulsating mass 75%, sensation of heat 66.67%, while pain, tissue necrosis, bleeding, port-win stain and cardiomegaly were the least symptoms and sings. All patients were treated by surgical excision after preoperative sclerotherapy. Conclusions: Surgical treatment of AVM is a challenging issue for vascular surgeons. To minimize the complications related with surgery, a multidisciplinary team approach should be considered.

Seizures and Brain Arterovenous Malformation: A Surgical Series.

Seizures are common symptoms of supratentorial arteriovenous malformations (AVMs). The potential risk factors for epilepsy in patients with AVMs are still controversial. The reported long-term outcome of seizures after surgical treatment of AVMs is variable and the data available are mainly from small retrospective case series.We identified all consecutive patients between 1990 and 2006 who underwent microsurgical resection of supratentorial AVMs at our institute. Pre-operative risk factors for seizures, intra-operative characteristics, long-term neurological disability, and seizure outcome (Engel's classification) were recorded and analyzed.During the study period, 110 patients underwent surgical resection of supratentorial AVM. Sixty of them (55 %) were symptomatic for seizures preoperatively. In our series, the absence of preoperative neurological deficits (p = 0.005), a large AVM size (p = 0.005), and no history of preoperative AVM hemorrhage (p < 0.001) were identified as risk factors for preoperative seizures. Following surgical resection, 77 % of patients with preoperative seizures had a modified Engel class I outcome. Among patients without a history of preoperative epilepsy, 56 % had new-onset seizures after surgical resection. None of the risk factors associated with preoperative seizures was associated with post-operative seizures. As there are no reliable factors predicting patients who may benefit from surgical treatment, epilepsy control should not be considered as the primary goal of AVMs surgery.

Risk factors for worsened muscle strength after the surgical treatment of arteriovenous malformations of the eloquent motor area.

OBJECT Case selection for the surgical treatment of arteriovenous malformations (AVMs) of the eloquent motor area remains challenging. The aim of this study was to determine the risk factors for worsened muscle strength after surgery in patients with this disorder. METHODS At their hospital the authors retrospectively studied 48 consecutive patients with AVMs involving motor cortex and/or the descending pathway. All patients had undergone preoperative functional MRI (fMRI) and diffusion tensor imaging (DTI), followed by resection. Both functional and angioarchitectural factors were analyzed with respect to the change in muscle strength. Functional factors included lesion-to-corticospinal tract distance (LCD) on DTI and lesion-to-activation area distance (LAD) and cortical reorganization on fMRI. Based on preoperative muscle strength, the changes in muscle strength at 1 week and 6 months after surgery were defined as short-term and long-term surgical outcomes, respectively. Statistical analysis was performed using the statistical package SPSS (version 20.0.0, IBM Corp.). RESULTS Twenty-one patients (43.8%) had worsened muscle strength 1 week after surgery. However, only 10 patients (20.8%) suffered from muscle strength worsening 6 months after surgery. The LCD was significantly correlated with short-term (p < 0.001) and long-term (p < 0.001) surgical outcomes. For long-term outcomes, patients in the 5 mm ≥ LCD > 0 mm (p = 0.009) and LCD > 5 mm (p < 0.001) categories were significantly associated with a lower risk of permanent motor worsening in comparison with patients in the LCD = 0 mm group. No significant difference was found between patients in the 5 mm ≥ LCD > 0 mm group and LCD > 5 mm group (p = 0.116). Nidus size was the other significant predictor of short-term (p = 0.021) and long-term (p = 0.016) outcomes. For long-term outcomes, the area under the ROC curve (AUC) was 0.728, and the cutoff point was 3.6 cm. Spetzler-Martin grade was not associated with short-term surgical outcomes (0.143), although it was correlated with long-term outcomes (0.038). CONCLUSIONS An AVM with a nidus in contact with tracked eloquent fibers (LCD = 0) and having a large size is more likely to be associated with worsened muscle strength after surgery in patients with eloquent motor area AVMs. Surgical treatment in these patients should be carefully considered. In patients with an LCD > 5 mm, radical resection may be considered to eliminate the risk of hemorrhage.

Seizure Predictors and Control After Microsurgical Resection of Supratentorial Arteriovenous Malformations in 440 Patients

Seizures are a common symptom of supratentorial arteriovenous malformations (AVMs), and uncontrolled epilepsy can considerably reduce patient quality of life. Potential risk factors for epilepsy in patients with AVMs are poorly understood, and the importance of achieving freedom from seizures in their surgical treatment remains underappreciated. To characterize risks factors for preoperative seizures and factors associated with postoperative freedom from seizures in patients with surgically resected supratentorial AVMs. We analyzed prospectively collected patient data for 440 patients who underwent microsurgical resection of supratentorial AVMs at our institution. Among 440 patients with supratentorial AVMs, 130 (30%) experienced preoperative seizures, and 23 (18%) with seizures progressed to medically refractory epilepsy. Seizures were associated with a history of AVM hemorrhage (relative risk, 6.65; 95% confidence interval [CI], 3.81-11.6), male sex (relative risk, 2.07; 95% CI, 1.26-3.39), and frontotemporal lesion location (relative risk, 1.75; 95% CI, 1.05-2.93). After resection, 96% of patients had a modified Engel class I outcome, characterized by freedom from seizures (80%) or only 1 postoperative seizure (16%; mean follow-up, 20.7 ± 2.3 months). Comparable rates of postoperative seizures were seen in patients with (7%) or without (3%) preoperative seizures. AVMs with deep artery perforators were significantly associated with postoperative seizures (hazard ratio, 4.35; 95% CI, 1.61-11.7). In the microsurgical treatment of supratentorial AVMs, hemorrhage, male sex, and frontotemporal location are associated with higher rates of preoperative seizures, whereas deep artery perforators are associated with postoperative seizures. Achieving freedom from seizure is an important goal that can be achieved in the surgical treatment of AVMs because epilepsy can significantly diminish patient quality of life.

[Clinical characteristics and surgical outcomes of 3094 patients with cerebral arteriovenous malformation].

To retrospectively analyze the clinical characteristics and surgical outcomes of 3094 patients with cerebral arteriovenous malformation (AVM) over a course of 53 years. The clinical data of 3094 consecutive AVM patients from July 1956 to April 2009 were collected and analyzed. The parameters included age (at diagnosis), gender, initial onset, Spetzler-Martin grade, relationship of lesion volume and blood, AVM with aneurysm, AVM with varices, surgical outcomes and mortality. Cerebral AVMs were more commonly diagnosed at a mean age of 27 ± 13 years old (range: 12 - 38). Hemorrhage (n = 1617, 52.26%), headache (n = 550, 17.78%) and seizure (n = 397, 12.83%) were the first three common presentations. A total of 1486 patients were estimated by Spetzler-Martin grading system. And the percentage of grades 2 - 4 patients was highly than that of other levels. The smaller the lesion volume, the greater risk of intracranial hemorrhage. Varices were found in 26 (0.84%) of 3094 AVM patients. And 12 (46.15%) patients with varices had a hemorrhage at presentation. Aneurysm was found in 66 (2.13%) of 3094 AVM patients. And 38 (57.58%) patients with varices had a hemorrhage at presentation. Among them, 2013 patients received microsurgery treatment. The outcomes were recovery (83.51%), excellence (12.42%), no change (0.60%), deterioration (0.30%) and death (3.18%). The surgical mortality of the patients with a hemorrhage at presentation was 5.19%. The first presentation of AVM is commonly apparent at a young age. And intracranial hemorrhage occurs often at dominant positions. AVM is one of the important reasons for spontaneous intracranial hemorrhage in youth. And the risk of hemorrhage is present for a patient's whole life. Microsurgery treatment can remove the lesion and eliminate the risk of hemorrhage immediately. With the applications of neurosurgery, navigation, ultrasound and intraoperative fluorescence angiography, the surgical treatment of AVM becomes safer and more reliable.

Computed tomography angiography based emergency microsurgery for massive intracranial hematoma arising from arteriovenous malformations

Digital subtraction angiography (DSA) and magnetic resonance angiography are the imaging modalities for the detection of intracranial arteriovenous malformations. However, these modalities are time consuming and cannot be used in emergency conditions. Computed tomography angiography (CTA) has also been shown to reliably detect vascular disorders such as cerebral arteriovenous malformations (AVMs). The purpose of this study was to evaluate the usefulness CTA in the surgical treatment of AVMs and the hematoma evacuation. Case records of 18 patients with massive intracranial hematoma secondary to AVMs were retrospectively reviewed. All patients had emergent brain CT and CTA. Follow-up DSA was performed two to three weeks after surgery. The outcome was assessed using Glasgow Outcome Scale (GOS). Results : Emergent CTA demonstrated AVMs and defined the feeding arteries, abnormal vascular nest, and draining veins in all the patients. Fourteen patients underwent hematoma evacuation and total resection of the AVMs, and four patients had hematoma evacuation and a partial resection. Follow-up DSA demonstrated complete resection of AVM in 14/18 patients and partial resection in 4 patients. There were no deaths and none of the patients had rebleeding in the follow up. A GOS scores during follow-up were: GOS 3 in 12 patients, GOS 4 in 4 patients and GOS 2 in 2 patients. CTA can be a reliable and rapid diagnostic tool for detecting underlying AVM in patients presenting with intracranial hematoma and for the pretreatment planning of emergency craniotomy.

The place for surgical treatment for AVM involving the temporal lobe

The objective of this study was to analyze preoperative symptoms and late clinical outcomes in patients who underwent surgical treatment of arterio-venous malformations (AVMs) of the temporal lobe, including those involving the Sylvian fissure (SF) and the lateral wall of the inferior ventricular horns-with special respect to postoperative hemiparesis and visual field defects (VFD). Between 1990 and 2007, 44 patients (n = 22 women, n = 22 men) with a mean age of 41 (12-67) years were operated on an AVM of the temporal lobe. All data had been collected prospectively. Patients' charts, as well as surgical reports and outpatient files, were analyzed. Thirteen patients showed an involvement of the SF, and six were localized partially in the lateral wall of the temporal horn. Eight AVMs were located in the temporo-mesial region. Fourteen patients had an AVM located mainly within the visual pathway. In 24 cases, the AVM was located in the dominant hemisphere. The AVMs were classified by the Spetzler-Martin grading system (SM). Visual fields were assessed in all patients pre- and postoperatively by independent ophthalmological examiners. The initial symptoms leading to the diagnosis of the AVM were seizures in 20 cases (45%), headache without hemorrhage in six cases (14%), incidental finding in five cases (11%), and tinnitus in two cases (5%). Hemorrhage had occurred in 15 cases (34%). Based on SM, 7 AVMs were grade I, 17 grade II, 17 grade III, and 3 grade IV. Preoperatively, seven patients presented with a VFD and two with a hemiparesis. Postoperatively, 8 of 44 (18%) patients presented with a new hemiparesis, remaining permanent in 3 of 44 (7%). In two of these patients, the AVMs were localized temporo-mesially (n = 2/8, 25%). Seven patients (19%) showed a new significant postoperative VFD, and in addition, three patients had worsening of their preexisting VFD (3/7, 43%). Postoperative angiography verified complete AVM occlusion in 43 of 44 (98%) cases. One patient needed reoperation for residual AVM; hence, in all patients, complete occlusion before discharge was achieved. Treatment of temporal lobe AVMs is demanding due to their close spatio-anatomical relationship with important neurovascular structures and the optic radiation. In this surgically treated series, morbidity for a new permanent hemiparesis was 7% and preservation of the visual field could be achieved in almost 90% of all cases. This is a calculable risk for most patients that renders microsurgical resection a justifiable option, even in light of other treatment modalities. The risk for new permanent motor deficits is elevated in temporo-mesial AVMs, and these patients have to be advised accordingly for surgical treatment.

Linear vein–based arteriovenous malformations in children

The authors reviewed the experience of a single surgeon in the surgical treatment of arteriovenous malformations (AVMs) in children, with specific attention to the angioarchitectural appearance of these lesions. Methods The authors performed a retrospective review of pediatric cases of AVM treated at a single institution over a 15-year period. Inclusion criteria consisted of pediatric age at time of treatment and resection of a pial AVM. The AVMs were considered linear-based if they had a single, centrally located, dominant vein with a linear configuration rather than the typical central nidus. Sixty-seven patients, ranging in age from 6 months to 17 years, underwent surgical treatment of an AVM between January 1, 1990, and December 30, 2005. In these patients, 31 AVMs (46%) had a distinct linear configuration that was centered on a dominant draining vein ("vein-based"). These AVMs presented with hemorrhage (61%), incidental findings on imaging (16%), or seizures (13%). In 4 cases, AVM recurrence was noted on angiographic follow-up after postoperative angiography showed no residual lesion. Recurrence was seen at 1 year in 2 cases, and at 3 and 11 years in 1 case each. A linear vein-based morphological pattern is common in pediatric AVMs and may recapitulate the embryological origins of the cerebral circulation. Surgical treatment in these cases can also be vein-based, through a narrow surgical corridor, which leads to minimal cortical disruption.

Surgical treatment of arteriovenous malformation in a child with haemophilia

Surgical treatment of arteriovenous malformation in a child with haemophilia

Intraoperative real-time contrast-enhanced ultrasound angiography: a new adjunct in the surgical treatment of arteriovenous malformations

Object The goal of this study was to combine the use of ultrasound contrast agents with intraoperative ultrasound techniques to identify intraoperatively a patient's vascular anatomy, including feeding arteries and draining veins of an intracranial arteriovenous malformation (AVM). Methods The authors examined 12 consecutive patients with AVMs that had been diagnosed on the basis of preoperative findings on magnetic resonance images and digital subtraction angiograms obtained between September 2003 and December 2005. After each patient had undergone a routine craniotomy, a bolus of contrast agent was injected intravenously, and a real-time microbubble perfusion process was observed to identify the feeding arteries and draining veins of the AVM in a single cross-section. The so-called burst–refill technique was used to sweep the lesion in multiple sections and orientations to obtain information on the surrounding vascular anatomy, after which the findings were compared with those obtained during preoperative imaging. Results Intraoperative ultrasonography provided high-quality images in every case. Although plain imaging failed to show an identifiable AVM boundary, color Doppler flow imaging clearly delineated the shape and margin of the AVM. Nevertheless, neither mode of imaging enabled the surgeons to categorically distinguish between feeding and draining vessels. The real-time perfusion process of microbubbles was first visualized 20 to 30 seconds after the SonoVue bolus injection, and the burst–refill technique made possible identification of the vascular anatomy of malformation lesions in multiple planes. Conclusions Using both an ultrasound contrast agent and the burst–refill technique provided a rapid, convenient, and precise way of locating AVM feeding arteries intraoperatively. The combined technique seems warranted in the intraoperative treatment of AVMs.