BACKGROUND Arteriovenous malformations (AVMs) are congenital dysplastic processes. What separates an AVM from the others dysplastic vascular malformations, as developmental venous anomalies, capillary telangiectasias and cavernous malformation, is the presence of an arteriovenous shunt, resulting in the absence of the normal capillary bed. These shunts are characterized by high flow and high pressure. Important characteristics of any AVM include nidus size and location, number and location of arterial feeders, and pattern of venous drainage. AVMs are dynamical entities and though extremely rare, they can spontaneously regress. The most common presenting symptom is an intracerebral or subarachnoid hemorrhage (41-79 %). Seizures are the second presenting symptom (15-30%) followed by headaches (15%). A relatively rare presentation for an unruptured AVM is neurological deficit. Treatment modalities include surgical resection, endovascular occlusion, radiosurgery or some combination of these approaches. OBJECTIVES A fourteen years experience related to the choice and timing of the single or combined treatment of the AVMs is reported, with special attention to the description of the surgical procedure. METHODS AND MATERIALS In a range period of 14 years (2000-2014), 74 surgical procedures are described to treat intracranial Arteriovenous Malformations (AVMs). The AVMs classification has been done with the “Spetzler-Martin system” and outcome has been evaluated through the “Glasgow outcome scale” (GOS). Preoperative studies of the patients have been performed with head CT scans, angio-CT, angio-MRI, functional MRI and angiography of intracranial vessels. The principles and tips&tricks of the surgical technique are showed. The surgical steps are: initial inspection, arachnoido-pial dissection, intraparenchimal dissection, periventricular dissection, AVM exeresis and final inspection. Thereafter, the auxiliary methodologies such as preservation and reconstruction of bypassing arteries, neuronavigation, intra-operative videoangiography and intra-operative neurophysiological monitoring are illustrated. The post-operative follow-up has been made with sequential head CT scans, angio-CT and angiography of intracranial vessels. RESULTS. This case series is related to 67 patients of which 38 males (56%) and 29 females (44%), with the average age of 38.6 (13-72); 72% (48) of AVMs were ruptured, 28% (19) were unruptured, 63 supratentorial (44 ruptured, 19 unruptured), 4 infratentorial (4 ruptured, 0 unruptured). 44 AVMs have been treated only with surgery, of which, 15 with life-saving procedure; 20 with embolization and surgery; 1 with surgery, embolization and radiosurgery; 2 with surgery and radiosurgery. The post-operative GOS is 5/5 for 27 patients, 4/5 for 30 patients, 3/5 for 8 patients, 2/5 for 1 patient and 1/5 for 1 patient. CONCLUSIONS AVMs are now being treated using multidisciplinary modalities. The decision as to whether or not to treat any given AVM is based upon a critical evaluation of the balance of the implicit risks (estimated and hypotetical) of the natural history of these lesions and the implicit risks of any therapeutic approach. The ideal treatment of the AVMs is their complete obliteration, partial treatment and reduction of the lesion (by surgery, endovascular techniques or radiosurgery) is not helpful and on the contrary may enhance up to three or four times the risks of bleeding.

INTRACRANIAL ARTERIOVENOUS MALFORMATIONS: SURGICAL TREATMENT

GALZIO, RENATO
2014-01-01

Abstract

BACKGROUND Arteriovenous malformations (AVMs) are congenital dysplastic processes. What separates an AVM from the others dysplastic vascular malformations, as developmental venous anomalies, capillary telangiectasias and cavernous malformation, is the presence of an arteriovenous shunt, resulting in the absence of the normal capillary bed. These shunts are characterized by high flow and high pressure. Important characteristics of any AVM include nidus size and location, number and location of arterial feeders, and pattern of venous drainage. AVMs are dynamical entities and though extremely rare, they can spontaneously regress. The most common presenting symptom is an intracerebral or subarachnoid hemorrhage (41-79 %). Seizures are the second presenting symptom (15-30%) followed by headaches (15%). A relatively rare presentation for an unruptured AVM is neurological deficit. Treatment modalities include surgical resection, endovascular occlusion, radiosurgery or some combination of these approaches. OBJECTIVES A fourteen years experience related to the choice and timing of the single or combined treatment of the AVMs is reported, with special attention to the description of the surgical procedure. METHODS AND MATERIALS In a range period of 14 years (2000-2014), 74 surgical procedures are described to treat intracranial Arteriovenous Malformations (AVMs). The AVMs classification has been done with the “Spetzler-Martin system” and outcome has been evaluated through the “Glasgow outcome scale” (GOS). Preoperative studies of the patients have been performed with head CT scans, angio-CT, angio-MRI, functional MRI and angiography of intracranial vessels. The principles and tips&tricks of the surgical technique are showed. The surgical steps are: initial inspection, arachnoido-pial dissection, intraparenchimal dissection, periventricular dissection, AVM exeresis and final inspection. Thereafter, the auxiliary methodologies such as preservation and reconstruction of bypassing arteries, neuronavigation, intra-operative videoangiography and intra-operative neurophysiological monitoring are illustrated. The post-operative follow-up has been made with sequential head CT scans, angio-CT and angiography of intracranial vessels. RESULTS. This case series is related to 67 patients of which 38 males (56%) and 29 females (44%), with the average age of 38.6 (13-72); 72% (48) of AVMs were ruptured, 28% (19) were unruptured, 63 supratentorial (44 ruptured, 19 unruptured), 4 infratentorial (4 ruptured, 0 unruptured). 44 AVMs have been treated only with surgery, of which, 15 with life-saving procedure; 20 with embolization and surgery; 1 with surgery, embolization and radiosurgery; 2 with surgery and radiosurgery. The post-operative GOS is 5/5 for 27 patients, 4/5 for 30 patients, 3/5 for 8 patients, 2/5 for 1 patient and 1/5 for 1 patient. CONCLUSIONS AVMs are now being treated using multidisciplinary modalities. The decision as to whether or not to treat any given AVM is based upon a critical evaluation of the balance of the implicit risks (estimated and hypotetical) of the natural history of these lesions and the implicit risks of any therapeutic approach. The ideal treatment of the AVMs is their complete obliteration, partial treatment and reduction of the lesion (by surgery, endovascular techniques or radiosurgery) is not helpful and on the contrary may enhance up to three or four times the risks of bleeding.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11697/33547
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