Management Strategies and Surgical Techniques for Deep-seated Supratentorial Arteriovenous Malformations

Abstract

The therapeutic options for arteriovenous malformations (AVMs) of the thalamus and the basal ganglia have expanded to include preoperative embolization, stereotactic radiation, and microsurgery. Adjuncts to surgery such as stereotactic guidance, electrophysiological monitoring, intraoperative ultrasound, intraoperative angiography, and induced hypotension have significantly reduced postoperative morbidity. We review the management and outcome of 65 consecutive patients who were treated for deep-seated supratentorial vascular malformations; 45 patients (69%) were treated surgically, 10 patients (15%) were treated conservatively, and 10 patients (15%) underwent radiosurgery. This retrospective study (1976-1993) includes 51 AVMs (78%), 14 cavernous angiomas (22%), and 10 associated vascular anomalies (15%). Initially, 59 (91%) of 65 patients presented with hemorrhage; 23 patients (39%) suffered recurrent hemorrhages. Malformations ranged in size from 1 to 7.5 cm (mean, 2.8 cm). AVMs were fed principally by the anterior and posterior choroidal, thalamoperforate, and lenticulostriate arteries. Venous drainage was uniform via the deep venous system. Among 39 patients who underwent surgery for AVMs, 26 (67%) improved, 7 (18%) remained unchanged, 5 (13%) worsened, and 1 (3%) died. Among six patients who underwent surgery for cavernous angiomas, four (66%) improved, one (17%) remained unchanged, and one (17%) worsened. Operative complications included transient neurological deficits in seven patients (16%), permanent neurological deficits in six patients (13%), and new bleeding from residual AVMs in four patients (9%). Among 10 patients treated conservatively, 3 (30%) had repeat hemorrhages, 2 (20%) had progressive neurological deficits, and 1 (10%) died.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiographic Examination of Spontaneous Putaminal Hemorrhage

“…The aneurysms that can cause a putaminal hemorrhage are those arising at the internal carotid artery bifurcation and peripheral MCA [12, 13], in addition to the MCA bifurcation. Striate AVMs involving the lenticular nucleus and external capsule region can be supplied by the lateral lenticulostriate artery, anterior choroidal artery, insular branches of the MCA, and so forth, where the venous drainage is usually into the internal cerebral veins [14, 15]. Moyamoya disease as an important cause of putaminal hemorrhages is covered in the report by Saeki et al [16], based on clinical analysis of the hemorrhagic type of moyamoya disease.…”

Population-based analysis of arteriovenous malformation treatment

“…Several specialized centers have presented excellent results from the operative treatment of small, deep-seated AVMs, including those in the basal ganglia, thalamus, and brainstem. 32,36 Many surgeons seem to prefer performing GKS in these critical locations, although GKS is not without complications. 7,17,29 For treatment of Grade 4 lesions, multimodality protocols, including various combinations of endovascular treatment, focused radiation treatment, and surgery, are currently on trial.…”

Gamma Knife Radiosurgery in the Management of Arteriovenous Malformations of the Basal Ganglia Region of the Brain

“…Sasaki et al [11] report a complication rate of 7.1 % and a mortality of 42.9 %. Tew et al [5] describe an incidence of progressive neurological deficits of 20 % and a death rate of 10 % during the FU period in 10 patients with BGAVMs who had never been treated. In contrast, studies of the natural history of AVMs in all other locations in the brain calculate a mortality risk of 10 % ± 15 % per decade [19 ± 21].…”

“…Decidedly encouraging results were reported in a few selected cases of angiomas superficially located on the head of the caudate nucleus-thalamus, adjacent to the ventricular system [13, 22 ± 24], or else laterally in the region of the insula, adjacent to the sylvian cistern [25]. However, it is not always possible to achieve radical excision of AVMs with microsurgery; angiography shows remnants of angiomas in 3 % ± 18 % of cases [1,5,8,13], with a consequent risk of post-microsurgical bleeding documented in 4.5 % ± 12.5 % of operated patients [5,8,12,13]. Furthermore, the rates of permanent morbidity and post-operative mortality (12.5 % ± 27 % and 6 % ± 12.5 %, respectively) are by no means negligible [8,9,12,13], even in recently published studies, which report permanent sequelae in 11 % ± 31 % of cases [1,4,5,11].…”