Multimodality treatment of deep periventricular cerebral arteriovenous malformations

doi:10.1016/0090-3019(92)90169-N

Surgical Neurology

Volume 38, Issue 3, September 1992, Pages 192-203

https://doi.org/10.1016/0090-3019(92)90169-N Get rights and content

Abstract

The surgical treatment of arteriovenous malformations (AVMs) located in deep periventricular regions such as the basal ganglia is associated with marked morbidity and mortality. Approaches through critical brain regions afford limited exposure of the lesions, while surgical dissection is sometimes complicated by acute severe brain swelling and/or hemorrhage in the surrounding tissues. In our approach to deep AVMs, our regimen has evolved from direct staged microsurgical excision under routine fentany-N₂O-relaxant anesthesia (first four patients) to the use of elective high-dose barbiturate anesthesia (subsequent 12 patients). In the first group of four patients, 11 operations were performed. Two patients improved, one of whom returned to normal neurologically. There were three episodes of acute brain swelling and/or hemorrhage. One patient died as a result, and another deteriorated. In the second group of 12 patients, all but two lesions were completely excised. Among the 10 patients in whom the AVM was completely excised, seven improved, six of whom achieved a good to excellent outcome, with two regaining full neurologic function. Three patients worsened (one as the result of acute brain swelling and/or hemorrhage). There was no death in this group. Only one incidence of acute brain swelling and/or hemorrhage occurred in 26 operations. Even though the number of patients is too small in the first group for meaningful statistical comparison, our intraoperative observations and postoperative results suggest that our evolved multimodality regimen, such as staged excision and the use of elective high-dose barbiturates, was likely to have contributed to the improved treatment results of these formidable lesions.

References (38)

BT Andrews et al.
Staged treatment of arteriovenous malformations of the brain
Neurosurgery
(1987)
GH Barnett et al.
Cerebral circulation during arteriovenous malformation operation
Neurosurgery
(1987)
HH Batjer et al.
Cerebrovascular hemodynamics in arteriovenous malformation complicated by normal perfusion pressure breakthrough
Neurosurgery
(1988)
HH Batjer et al.
Evidence of redistribution of cerebral blood flow during treatment for an intracranial arteriovenous malformation
Neurosugery
(1989)
H Batjer et al.
Arteriovenous malformations of the posterior fossa
J Neurosurg
(1986)
A Berenstein et al.
Percutaneous embolization of arteriovenous fistulas of the external carotid artery
AJNR
(1986)
AL Day et al.
Successful treatment of the normal perfusion pressure breakthrough syndrome
Neurosurgery
(1982)
CG Drake
Arteriovenous malformations of the brain
CG Drake
Cerebral arteriovenous malformations: considerations for and experience with surgical treatment in 166 cases
Clin Neurosurg
(1979)
JC Drummond et al.
Effect of the acute administration of high dose pentobarbital on human brain stem auditory and median nerve somatosensory evoked responses
Neurosurgery
(1987)

JC Drummond et al.

The effect of high dose sodium thiopental on brain stem auditory and median nerve somatosensory evoked responses in humans

Anesthesiology

(1985)

JM Eskridge et al.

Preoperative embolization of brain AVMs using surgical silk and polyvinyl alcohol

AJNR

(1989)

C Iadecola et al.

Do cholinergic neurons of the basal forebrain cholinergic system mediate the cortical vasodilation elicited by fastigial nucleus stimulation in rats?

J Cereb Blood Flow Metab

(1983)

C Kerber

Balloon catheter with a calibrated leak

Radiology

(1976)

II Kricheff et al.

Transfemoral catheter embolization of cerebral and posterior fossa arteriovenous malformations

Radiology

(1972)

P Lasjaunias et al.

Endovascular treatment of cerebral arteriovenous malformations

Neurosurg Rev

(1986)

AJ Luessenhop et al.

Artificial embolization of cerebral arteries

GM Malik et al.

Microsurgical removal of arteriovenous malformations of the basal ganglia

Neurosurgery

(1988)

LF Marshall et al.

Treatment of massive intraoperative brain swelling

Neurosurgery

(1983)

Cited by (23)

Endovascular management of arteriovenous malformations
2017, Handbook of Clinical Neurology
Citation Excerpt :
Alternatively, small eloquent AVMs may be considered for radiosurgery at the discretion of the surgeon. Intermediate to larger-size AVMs (more than 3 cm) and/or Spetzler–Ponce grade B or C AVMs provide a greater therapeutic challenge and are often best managed via multimodality approaches, including endovascular embolization (U et al., 1992; Lawton et al., 1995; Chang et al., 2003; Weber et al., 2007; Natarajan et al., 2008; Starke et al., 2009; Crowley et al., 2015). Other indications for embolization include the need to expediently obliterate a high-risk feature (associated aneurysm) and, rarely, to attempt cure in patients with surgically inaccessible, small lesions that require expedient treatment (ruptured, small, deep AVMs) (Haw et al., 2006; Krings et al., 2010; van Rooij et al., 2012; Crowley et al., 2015).
Arteriovenous malformation (AVM) embolization can serve as a crucial adjunct before surgical resection, a partial approach to target high-risk features, or, rarely, as a curative approach for high-risk, surgically inaccessible lesions. Specifically, embolization is a welcome surgical adjunct to reduce the size of medium to large AVMs, to target perforator supply, and/or to target the deep portion of a nidus. In addition, a crucial role for embolization is the targeting of associated aneurysms, particularly in the setting of a ruptured lesion, regardless of the subsequent therapeutic modality. Rarely, a deep, small ruptured AVM that cannot be accessed surgically may be embolized with intent to cure. This chapter will review patient selection, technical nuances, and published results for AVM embolization. With appropriate patient selection and well-defined goals of embolization, the risk of procedural morbidity can be outweighed by its benefit.
Arteriovenous malformations
2002, Lancet
Citation Excerpt :
A multidisciplinary approach does not have to incorporate all three treatment types in an individual patient, however all three options should be available to facilitate a holistic approach during treatment planning. These strategies have been well described, and a detailed review is beyond the scope of this review.78,79,105–126 However, Hoh and colleagues127 used multimodal treatment in 40 children with arteriovenous malformations, and were the first to report such treatment in children.
Arteriovenous malformations of the brain are congenital vascular lesions that affect 0·01–0·50% of the population, and are generally present in patients aged 20–40 years. The usual clinical presentations are haemorrhage, seizures, progressive neurological deficit, or headache. Results of natural history studies have shown a yearly haemorrhage rate of 1–4%. Frequency of rebleeding has increased over the years, and several factors that increase risk of haemorrhage have been identified. Although substantial, the morbidity associated with haemorrhages could be less than previously thought. Over the past decade, great advances have been made in application of endovascular embolisation techniques, stereotactic radiosurgery, and microsurgery, allowing effective multidisciplinary treatment of arteriovenous malformations, including those previously deemed to be untreatable. Increasing attention has been paid to management of flow-related aneurysms associated with these malformations. Finally, many reports of recurrent arteriovenous malformations have coincided with new theories regarding the embryogenesis of these disorders and laboratory work suggesting their proliferative potential.
Anesthetic issues associated with midline transfacial approaches
2000, Operative Techniques in Neurosurgery
The anesthetic management of patients undergoing procedures using midline transfacial approaches requires a clear understanding of lesion anatomy and surgical plan. A thorough preoperative anesthetic evaluation is necessary for all patients. Patients with extensive tumors of epithelial origin are frequently older with comorbid medical conditions. The examination should include evaluation of overall physical, metabolic, and nutritional status in addition to cardiovascular, pulmonary, and neurologic systems. Pulmonary function and anti-ischemic and antihypertension therapies should be optimized before surgery. Careful perioperative airway management is required. Awake fiberoptic intubation or elective, awake surgical securement of the airway may be required. Anesthetic technique should be tailored to the patient's physical status and specific intraoperative requirements, such as neurophysiological monitoring. Venous access must be sufficient to treat rapid and extensive blood loss. Invasive cardiovascular monitoring, such as central venous catheters, pulmonary artery catheters, or transesophageal echocardiography, may be necessary. Mild intraoperative hypothermia may be useful for brain protection, but its use should be weighed against possible deleterious effects on reconstructive soft tissue flaps. Postoperative care must include meticulous attention to airway, pulmonary, cardiovascular, and neurological status. These patients are at increased risk for delayed awakening, postoperative delirium, or both. Because of the potential for severe postoperative complications, most patients undergoing these procedures should remain in an intensive care setting for at least 24 hours postprocedure. Knowledge of the pathophysiology underlying these potential complications is necessary for formulating a rational anesthetic plan.
Selection of treatment modalities for cerebral arteriovenous malformations: A retrospective analysis of 348 consecutive cases
2000, Journal of Clinical Neuroscience
The objective was to establish the selection criteria for the optimal management modalities for cerebral arteriovenous malformations. We analysed the complications and late outcomes in 348 consecutive cases (132 microsurgical resections, 202 stereotactic radiosurgeries, 8 embolisations only, 6 combined treatments) managed at Yonsei University Hospital from 1988 to 1997. Files for all patients were analysed. The outcome was classified into good for the patients who returned to their previous job with or without neurological deficits, fair for the patients who were unable to return to work but performed daily activities independently with minor deficits, and poor for the patients who were performing dependent daily activities with major deficits. The outcome of microsurgery was considered good in 108 patients (81.8%), fair in 18 (13.6%), poor in 4 (3.1%), and 2 (1.5%) patients died. Initial insults and haemodynamic complications were the major cause of an unfavourable outcome. The cumulative occlusion rate of the nidus after radiosurgery was 10.2% within 12 months, 75.3% within 24 months, and 89.8% within 36 months. Perilesional imaging changes with neurological deficits (4 permanent and 6 transient, 4.8%) and haemorrhage (16 patients, 7.7%) during the latent interval were the major cause of an unfavourable outcome (1 poor, 4 dead after radiosurgery). Postradiosurgery bleeding occurred frequently within 6 months (6 patients), and between 13 and 24 months (8 patients). In conclusion, selection of treatment modality for cerebral AVMs depends on the preoperative evaluation of the risk/benefit ratio in each case. Microsurgical removal, which eliminates the risk of bleeding immediately, is preferred for lesions in non-eloquent areas. Radiosurgery is an effective treatment modality for small lesions in eloquent areas, but has a substantial risk of haemorrhage during the latency period. Results of this study suggest that microsurgical removal should be considered for lesions in eloquent areas with high haemorrhage risk, such as prior haemorrhage, medium to large size lesion, and single deep venous drainage.
Neuro-ophthalmology of arteriovenous malformations
1999, Neurosurgery Clinics of North America
A joint protocol for the neurosurgical and neuroradiologic treatment of cerebral arteriovenous malformations: Indications, technique, and results in 76 cases
1993, Surgical Neurology
We report on a group of 76 patients who had been treated during a period in which preoperative embolization using interventional neuroradiologic technique was standard procedure. During this time, 20 consecutive patients were operated on without embolization, eight patients were treated with embolization only, and 48 patients were operated on after embolization. In 35 cases surgery immediately followed the last embolization procedure. All arteriovenous malformations (AVMs) were classified and the outcome analyzed according to Spetzler [J Neurosurg 1986;65:476-83]. Those lesions treated with a combination of embolization and surgery had higher Spetzler grading than those that had been operated without previous embolization. The overall recovery rate was 82.9%. In 7.9% of the cases the AVMs were not totally extirpated. The overall complication rate was 9.2%. It is concluded that preoperative embolization facilitates surgery and reduces the risk of severe morbidity and mortality, especially in high-grade lesions. In addition to the clinical results, the application and usefulness of Ethibloc® as an embolizing agent is reported.

View all citing articles on Scopus

View full text

Multimodality treatment of deep periventricular cerebral arteriovenous malformations

Abstract

Staged treatment of arteriovenous malformations of the brain

Neurosurgery

Cerebral circulation during arteriovenous malformation operation

Neurosurgery

Cerebrovascular hemodynamics in arteriovenous malformation complicated by normal perfusion pressure breakthrough

Neurosurgery

Evidence of redistribution of cerebral blood flow during treatment for an intracranial arteriovenous malformation

Neurosugery

Arteriovenous malformations of the posterior fossa

J Neurosurg

Percutaneous embolization of arteriovenous fistulas of the external carotid artery

AJNR

Successful treatment of the normal perfusion pressure breakthrough syndrome

Neurosurgery

Arteriovenous malformations of the brain

Cerebral arteriovenous malformations: considerations for and experience with surgical treatment in 166 cases

Clin Neurosurg

Effect of the acute administration of high dose pentobarbital on human brain stem auditory and median nerve somatosensory evoked responses

Neurosurgery

The effect of high dose sodium thiopental on brain stem auditory and median nerve somatosensory evoked responses in humans

Anesthesiology

Preoperative embolization of brain AVMs using surgical silk and polyvinyl alcohol

AJNR

Do cholinergic neurons of the basal forebrain cholinergic system mediate the cortical vasodilation elicited by fastigial nucleus stimulation in rats?

J Cereb Blood Flow Metab

Balloon catheter with a calibrated leak

Radiology

Transfemoral catheter embolization of cerebral and posterior fossa arteriovenous malformations

Radiology

Endovascular treatment of cerebral arteriovenous malformations

Neurosurg Rev

Artificial embolization of cerebral arteries

Microsurgical removal of arteriovenous malformations of the basal ganglia

Neurosurgery

Treatment of massive intraoperative brain swelling

Neurosurgery