Technical Note
Trans-venous embolization of a basal ganglia ruptured arteriovenous malformation with open surgical arterial control: A hybrid technique

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Abstract

Treatment of ruptured deep-seated arteriovenous malformations is challenging and associated with elevated risks. This is due to the proximity or involvement of critical brain structures and the specifically fine and delicate angioarchitecture of these lesions, making both endovascular and surgical access technically complicated. We present the advantages of a true combined, open surgical and endovascular transvenous approach in a hybrid operating room. The technique may overcome in part the difficulties and may improve safety and risk related concerns.

Introduction

The risk of hemorrhage of deep-seated arteriovenous malformations (AVM) is three- to four-fold that of AVMs in general, with a > 9.8% risk of bleeding per patient/year [1], [2]. The mortality of an eventual rebleeding is very high (62.5%) [2], therefore ruptured lesions are usually treated to avoid further bleedings. However, risks of interventions remain high and will add to the initial hemorrhage related morbidity, with rates of around 20% of bad outcome with mRS > 2 in the surviving patients [2], [3]. This is related mostly to the proximity of critical structures (internal capsule) and the complex angioarchitecture of these lesions. The feeding perforating arteries often give branches to normal brain tissue, the nidus may involve the anterior limb of the internal capsule besides the basal ganglia and the draining veins run towards the deep system. The aim of the acute treatment is the elimination of the nidus or at least of the rupture point. As radiosurgery is usually not considered as a primary option, embolization and surgery alone or in combination are the remaining modalities in the acute setting. The drawbacks of the endovascular approach are related to poor access and bleeding control, while surgery is associated with further critical tissue damage, all increasing procedural morbidity.

We present a combined, hybrid endovascular and surgical approach of ruptured basal ganglia AVM aiming to reduce risks of AVM-exclusion.

Section snippets

Case history

A patient in his forties was hospitalized comatose with severe left hemisyndrome and right mydriasis. A voluminous right basal ganglia and internal capsule hematoma with intraventricular components was detected with important mass effect (Fig. 1A). The CTA raised the suspicion of small basal ganglia AVM (Fig. 1B). Emergency decompressive craniectomy and hematoma evacuation was performed, without aiming for the AVM nidus. Post-surgery DSA demonstrated the small striatal AVM, with ill-defined

Surgical technique

The head of the patient was positioned and fixed in a Mayfield-frame. The femoral artery was punctured and a standard DSA and a vaso-CT of the right ICA was performed, showing the pre-nidal aneurysm, which further increased in size over time. With image guided augmented reality assisted neuronavigation [4], the Sylvian fissure was opened and the feeding lenticulostriate artery identified and isolated. A temporary microclip was placed proximal to the entry point in the anterior perforating

Discussion

The decision on the treatment of choice of ruptured deep brain AVMs should be based on a thorough diagnostic work-up, aiming to identify the rupture point, usually marked by a pre- or intranidal pseudo-aneurysm. The most convenient access to the bleeding site, endovascular or surgical, should guide the treatment strategy. Surgical excision as a primary option is chosen if the nidus or rupture point can be surgically accessed and fore-seen to be found during surgery without damaging critical

Conclusion

For the safety of trans-venous embolization, feeder control from the arterial side should be available. If this cannot be achieved by transarterial superselective catheterization, the surgical isolation and control of the pedicle artery can offer the solution, thus reducing the risk of trans-venous approach.

Disclosure of interest

The authors declare that they have no competing interest.

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© 2018 Published by Elsevier Masson SAS.