Cerebral AVMs are known to be a source of intracranial hemorrhages and epileptic seizures. Their natural history indicates approximately 15% mortality and 35% morbidity over a 15-year period. This significant mortality and morbidity mandates a need for satisfactory treatment of this entity, ideally by elimination of AVMs. Microsurgical resection, endovascular embolization and radiosurgery (irradiation) are the three effective modes of treatment currently available. However, no objective criteria have been established for which mode(s) of treatment should be selected for individual patients with AVMs. Considering the complexity of AVMs and variable conditions of individual patients, neurosurgeons, intravascular interventionalists and radiosurgeons must make their own decisions on how to treat each patient based on their experience. In practice, treatment of small AVMs in non-functional areas is favored equally by each of these specialists, while they tend to avoid treatment of large AVMs, particularly those in functional areas of the brain. The authors report the surgical intervention of large AVMs, including those located in functional areas of the hemisphere by special techniques. One can demonstrate AVM compartments by using angiography and with the aid of color Doppler ultrasonography, each compartment can be outlined and dissected individually until all the compartments are isolated without causing any damage to the surrounding brain and the entire AVM is rendered shrunken and then removed. The concept of compartmental treatment of AVMs may be applied in the future to radiosurgery and intravascular embolization of large AVMs.
In 1907, the technique of continuous spinal anaesthesia (CSA) was introduced using intermittent injections of amylocaine via a needle which remained in the spinal canal. 1 This technique was refined in 1944 by threading a ureteral catheter into the lumbar subarachnoid space,2 and subsequently has been performed with standard epidural equipment. In an attempt to decrease the complication of post-dural puncture headache following CSA with standard epidural equipment, a microcatheter technique has been developed. 3,4 Neurological deficits following spinal anaesthesia are rare. 5 However, cauda equina syndrome following CSA has been reported recently. 6 We report two cases of persistent sacral nerve root deficits following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. A neurologist was involved in the postoperative care to validate the deficits. In each case, CSA was performed with hyperbaric lidocaine through a lumbar microcatheter.Case #1 A 67-yr-old male with normal coagulation studies and neurological examination was prepared (10% povidoneiodine solution (Kendall Healthcare)), and a 22-gauge spinal needle was introduced easily into the subarachnoid space (L3-4). A 28-gauge CSA catheter (CoSpan~, Kendall Healthcare; Mansfield, MA) was inserted (4 cm) without difficulty and its position was verified by the aspiration of cerebrospinal fluid. In the supine position, 0.7 ml, 5% lidocaine in 7.5% dextrose (without epinephfine) was given, and followed by four incremental injections. The total dose before incision was 3.2 ml over 20 min. There was no pain or paraesthesia with needle placement, catheter insertion, or local anaesthetic injection. After surgical incision, another 2.5 ml (three injections) of 5% lidocaine were administered over ten minutes with the patient in the lithotomy position. Though
The natural history of patients with arteriovenous malformations (AVM's) suggests that serious morbidity associated with AVM's in functional areas is likely to be much greater than in silent areas. Various modes of treatment of AVM's in functional areas, including direct surgical intervention, embolization, and irradiation, have been considered to carry high risks. The authors advocate direct surgical intervention to these AVM's via a microsurgical technique based on knowledge of the hemodynamic anatomy of AVM's. The technique is designed to circumscribe the AVM without removing any surrounding cortical tissue or white matter and to preserve microcirculation in the functional area. Controlled hypotension (mean arterial blood pressure 40 to 60 mm Hg) is appropriate to enhance the safety of surgical procedures without causing metabolic and electrophysiological dysfunction. Another means to prevent neurological complications is multi-staged resection of larger AVM's, which permits obliteration compartment by compartment. This technique has the advantage of maintaining circulatory sufficiency in the functional area. There was no mortality among 56 patients who underwent the surgical procedure described. Of those, 55 patients resumed their preoperative occupation and one patient became self-sufficient.
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