Download PDF
Bendok, Bernard R. et al.: 2025 Hemorrhagic and Ischemic Stroke DOI: 10.1055/b-0044-205926
Section III Open Surgical, Minimally Invasive and Microsurgical Approaches

25 Microsurgery for Intracranial Arteriovenous Malformations

More Information

Book

Editors: Bendok, Bernard R.; Batjer, H. Hunt

Authors: Abi-Aad, Karl; Abuelem, Tarek; Açiş, Onur; Agnoletto, Guilherme J.; El Ahmadieh, Tarek; Albuquerque, Felipe C.; Amenta, Peter S.; Amoss, James; Aoun, Salah G.; Arthur, Adam S.; Awad, Issam A.; Ban, Vin Shen; Barrow, Daniel L.; Bebawy, John F.; Biller, José; Binning, Mandy J.; Blech, Benzion; Bonney, Phillip A.; Brasiliense, Leonardo B.C.; Carlin, Rachel E.; Carrión-Penagos, Julián; Chong, Brian W.; Christel, Lynda M.; Church, Ephraim W.; Connolly, E. Sander; Connor, Michelle; Dalfino, John C.; Demaerschalk, Bart M.; Dumitrascu, Oana M.; Entezami, Pouya; Felbaum, Daniel; Freeman, W. David; Garcia, Jose Omar; Goyal, Nitin; Granja, Manuel F.; Hanel, Ricardo A.; Heiferman, Daniel M.; Hemphill, J. Claude; Hess, Ryan; Howard, Brian M.; Hudson, Miles; Ingall, Timothy J.; Inoa, Violiza; Jabbour, Pascal M.; Jacob, Sneha; Johnson, Mark D.; Kalen, Brian; Kicielinski, Kimberly P.; Koester, Stefan W.; Koht, Antoun; Kondziolka, Douglas; Krishna, Chandan; Kronenburg, Annick; Kumar, Gyanendra; Langer, David; Levy, Elad I.; Mack, William J.; Merrill, Sarah; Meyer, Fredric B.; Monteiro, André; Montaño, Arturo; El Naamani, Kareem; Nossek, Erez; O’Carroll, Cumara B.; Ogilvy, Christopher S.; Ogunsola, Oludotun; Ottenhoff, Lauren; Oushy, Soliman; Patel, Bhavesh; Patra, Devi P.; Peacock, Sarah; Pena, Austin; Pines, Andrew; Polster, Sean P.; Rahme, Rudy J.; Rebeiz, Tania; Riina, Howard; Rinaldo, Lorenzo; Sattur, Mithun G.; Sen, Ayan; Siegel, Jason; Sim, Justin L.; Simon, Scott D.; Solomon, Robert A.; Spetzler, Robert; Sweid, Ahmad; Syal, Arjun; Tomlinson, Amanda; Turcotte, Evelyn L.; Turkmani, Ali H.; Vakharia, Kunal; Vanderhye, Vanesa K.; Veznedaroglu, Erol; Walia, Parampreet Singh; Waqas, Muhammad; Welch, Babu G.; Welz, Matthew E.; White, Jonathan A.; Winter, JoDee; Zaatar, Muriel T.; Zeeni, Carine

Title: Hemorrhagic and Ischemic Stroke

Subtitle: Medical, Imaging, Surgical, and Interventional Approaches

Print ISBN: 9781684200436; Online ISBN: 9781684203819; Book DOI: 10.1055/b000000291

2. Edition © 2025. Thieme. All rights reserved.
Thieme Medical Publishers, Inc., New York

Subjects: Neurosurgery

Thieme Clinical Collections (English Language)



 
Devi P. Patra, Evelyn L. Turcotte, Ryan Hess, Rudy J. Rahme, Matthew E. Welz, Chandan Krishna, H. Hunt Batjer, and Bernard R. Bendok

Abstract

Intracranial arteriovenous malformation (AVM) is an important cause of hemorrhagic stroke and is one of the most common cause in young individuals. Angioarchitecture of the AVM and the location of the lesion are primary determinants of the risk of hemorrhage that guides treatment. Microsurgery, endovascular embolization and radiosurgery are the three primary modalities of treatment which are used as sole treatment modalities or in combinations. Various grading scales including Spetzler and Martin and Spetzler and Ponce classification scales have been proposed to provide an estimate of surgical risk based on three parameters that includes the size of the nidus, pattern of venous drainage and eloquence of the brain tissue involved. Lower grade AVMs in a non-eloquent location are the ideal lesions amenable for surgical resection. However, higher grade tumors can often be deemed resectable with the use of multimodal treatment including preoperative embolization, radiosurgery by reducing the size of the lesion and controlling the deep feeders. Few important technical nuances for successful microsurgery are generous size of the craniotomy to allow visualization of the feeders and draining veins, early identification of feeders and draining veins often with the help of intraoperative indocyanine angiography, protection of the draining veins till the end, circumferential dissection of the nidus with coagulation/clipping of the arterial feeders and final ligation and division of the vein. Postoperative control of blood pressure often below the baseline is essential to prevent postoperative perfusion pressure breakthrough and hemorrhage. Successful microsurgical resection with complete obliteration of the nidus provides an immediate cure and near universal protection from future hemorrhage.

Key words

arteriovenous malformation - microsurgery - brain hemorrhage - vascular malformation
 
  • 3 Gandhi RT, Bendok BR, Getch C, Parrish TB, Batjer HH. Correlation of functional MRI with intraoperative cortical mapping in patient with cerebral arteriovenous malformation.. J Am Coll Surg 2001; 192 (6) 793 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 4 Ansari SA, Schnell S, Carroll T et al. Intracranial 4D flow MRI: toward individualized assessment of arteriovenous malformation hemodynamics and treatment-induced changes.. AJNR Am J Neuroradiol 2013; 34 (10) 1922-1928 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 5 Eddleman CS, Jeong HJ, Hurley MC et al. 4D radial acquisition contrast-enhanced MR angiography and intracranial arteriovenous malformations: quickly approaching digital subtraction angiography.. Stroke 2009; 40 (8) 2749-2753 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 10 Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery.. Neurosurgery 2010; 66 (4) 702-713, discussion 713 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 11 Yamada S, Takagi Y, Nozaki K, Kikuta K, Hashimoto N. Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations.. J Neurosurg 2007; 107 (5) 965-972 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 12 Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial.. Lancet 2014; 383 (9917) 614-621 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 13 Wong J, Slomovic A, Ibrahim G, Radovanovic I, Tymianski M. Microsurgery for ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformation): eligible unruptured brain arteriovenous malformations.. Stroke 2017; 48 (1) 136-144 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 14 Elhammady MSA, Gaynor BG, Peterson EC, Heros RC. Microsurgery of arteriovenous malformations. In: Winn H, ed. Youmans and Winn Neurological Surgery. 7th ed. Philadelphia, PA: Elsevier; 2016:3488–3508
  • 15 Spetzler RF, Hargraves RW, McCormick PW, Zabramski JM, Flom RA, Zimmerman RS. Relationship of perfusion pressure and size to risk of hemorrhage from arteriovenous malformations.. J Neurosurg 1992; 76 (6) 918-923 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 18 Brown Jr RD, Wiebers DO, Forbes GS. Unruptured intracranial aneurysms and arteriovenous malformations: frequency of intracranial hemorrhage and relationship of lesions.. J Neurosurg 1990; 73 (6) 859-863 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 19 Redekop G, TerBrugge K, Montanera W, Willinsky R. Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage.. J Neurosurg 1998; 89 (4) 539-546 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 20 Pollock GA, Shaibani A, Awad I, Batjer HH, Bendok BR. Intraventricular hemorrhage secondary to intranidal aneurysm rupture-successful management by arteriovenous malformation embolization followed by intraventricular tissue plasminogen activator: case report.. Neurosurgery 2011; 68 (2) E581-E586, discussion E586 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 21 Alaraj A, Amin-Hanjani S, Shakur SF et al. Quantitative assessment of changes in cerebral arteriovenous malformation hemodynamics after embolization.. Stroke 2015; 46 (4) 942-947 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 22 Pines A, Aoun RJ, Halasa TK, Sattur M, Zammar SG, Bendok BR. Toward individualized neurosurgery: quantifying arteriovenous malformation embolization with magnetic resonance angiography.. World Neurosurg 2015; 84 (5) 1184-1185 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 23 Markl M, Wu C, Hurley MC et al. Cerebral arteriovenous malformation: complex 3D hemodynamics and 3D blood flow alterations during staged embolization.. J Magn Reson Imaging 2013; 38 (4) 946-950 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 24 Donzelli GF, Nelson J, McCoy D et al. The effect of preoperative embolization and flow dynamics on resection of brain arteriovenous malformations.. J Neurosurg 2019; 132 (6) 1836-1844 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 27 El Ahmadieh TY, Aoun SG, Adel JG, Rosenow JM, Koht A, Bendok BR. Microsurgical treatment of a premotor arteriovenous malformation: 3-dimensional illustration.. Neurosurgery 2013; 72 (1) (Suppl. Suppl Operative) 1 PubMed
    PubMedSearch in Google Scholar
  • 28 Gross BA, Duckworth EA, Getch CC, Bendok BR, Batjer HH. Challenging traditional beliefs: microsurgery for arteriovenous malformations of the basal ganglia and thalamus.. Neurosurgery 2008; 63 (3) 393-410, discussion 410–411 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 30 al-Rodhan NR, Sundt Jr TM, Piepgras DG, Nichols DA, Rüfenacht D, Stevens LN. Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations.. J Neurosurg 1993; 78 (2) 167-175 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 31 Pradilla G, Coon AL, Huang J, Tamargo RJ. Surgical treatment of cranial arteriovenous malformations and dural arteriovenous fistulas.. Neurosurg Clin N Am 2012; 23 (1) 105-122 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 32 Choudhri O, Chang SD, Steinberg GK. Surgical and radiosurgical management of grade IV and V arteriovenous malformations. In: Winn H, ed. Youmans and Winn Neurological Surgery. 7th ed. Philadelphia, PA: Elsevier; 2016:3509–3524
  • 33 O’Shaughnessy BA, Getch CC, Bendok BR, Batjer HH. Microsurgical resection of infratentorial arteriovenous malformations.. Neurosurg Focus 2005; 19 (2) E5 PubMed
    PubMedSearch in Google Scholar
  • 34 Theofanis T, Chalouhi N, Dalyai R et al. Microsurgery for cerebral arteriovenous malformations: postoperative outcomes and predictors of complications in 264 cases.. Neurosurg Focus 2014; 37 (3) E10 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 35 Ali MJ, Bendok BR, Rosenblatt S, Rose JE, Getch CC, Batjer HH. Recurrence of pediatric cerebral arteriovenous malformations after angiographically documented resection.. Pediatr Neurosurg 2003; 39 (1) 32-38 PubMed
    CrossrefPubMedSearch in Google Scholar
  • 36 Colby GP, Coon AL, Huang J, Tamargo RJ. Historical perspective of treatments of cranial arteriovenous malformations and dural arteriovenous fistulas.. Neurosurg Clin N Am 2012; 23 (1) 15-25 PubMed
    CrossrefPubMedSearch in Google Scholar