Present State of Microneurosurgery of Cerebral Arteriovenous Malformations

Abstract

Microneurosurgical excision is known to be the definitive treatment for brain arteriovenous malformation (AVMs). The most important factors governing the operability of an AVM are location, size, age of the patient, and the neurosurgeon's and team's experience. We present in this review the surgical experience of the senior author (JH) in microneurosurgical treatment of brain AVMs. This consists of the following steps: (1) accurate preoperative embolization; (2) optimal selection of the surgical approach; (3) accurate definition and preservation of the normal arterial vessels of passage; (4) temporary clipping of the feeding arteries; (5) a special method of coagulation called "dirty coagulation" of the deep small difficult vessels inside apparently normal brain around the AVM; (6) removal of all AVM; (7) meticulous hemostasis; (8) intra- and postoperative digital subtraction angiography (DSA); (9) clinical and radiological follow-up. These steps are not possible in AVMs lying entirely within central eloquent areas. Nine out of ten small- and medium-sized arteriovenous malformations (AVMs) are suitable for direct surgery, but surgical complications increase drastically with the size of the AVM. Nevertheless, the actual results of combined treatment with preoperative Onyx embolization followed by microsurgery have decreased these risks.

Emergency endovascular treatment of petrous carotid artery false aneurysm

“…The endovascular armamentarium has advanced progressively so as, nowadays, it is considered to be the first line of defense against most complex and critical vascular pathologies. With specific regard for the treatment of IFA, or infectious aneurysms, endovascular procedures, including covered stent reconstruction, coil embolization, and parent vessel occlusion were progressively proposed and increasingly adopted to address the challenges related to the absence of a proper aneurysmal neck [3,[13][14][15][16]18,[21][22][23][24][25][26]. Nevertheless they are not always technically feasible [13,23].…”

Cerebrovascular neurosurgery 2011

“…These results should reinforce the importance of innovative endovascular strategies to make large AVMs amenable to subsequent curative surgical or radiosurgical therapy. 34,35 The highly experienced group of Saatci et al reported their extensive experience with endovascular embolization of 350 AVMs with Onyx Liquid Embolic Material (ev3) with a slow ''staged'' reflux technique. 11 They reported a remarkable 51% angiographic obliteration rate for endovascular therapy alone with permanent morbidity and mortality rates of 7% and 1.4%, respectively.…”

Central Nervous System Vascular Malformations

“…It is generally accepted that the risk of surgery is low (<10%) in Spetzler-Martin (SM) grade 1 and 2 lesions [68][69][70][71]. Spetzler-Martin grade 3 AVMs are a heterogenous group, and complication rates depend largely on the morphology of these lesions, with some having a risk profile similar to that of small (SM grade 1 & 2) AVMs, and some having a risk profile similar to that of large (SM grade 4 & 5) AVMs [72][73][74].…”