Surgery for Cerebral Arteriovenous Malformation

Introduction Arteriovenous malformation (AVM) excision is a challenge for neurosurgeons. There is always a high risk of intraoperative bleeding. It is not only because of the abnormal vessels in the AVM, but also due to the change in hemodynamics of the surrounding brain. As the surgery proceeds, surrounding brain becomes more hyperemic and may start bleeding.

Bleeding may start from the nidus. The reason may be:

• Coagulation of the draining vessels with persistent arterial feeder

• Inadequate feeder coagulation

• Persistent residual/daughter nidus

• Inadequate intraoperative blood pressure control

The aims of AVM surgery are:

• Excision of the nidus only.

• Preservation of the surrounding brain.

Material and Methods This presentation is based on personal experience and retrospective analysis of 350 patients who underwent surgery for the excision of AVM in our department.

Surgical Technique The basic principle of AVM surgery is different from tumor excision. The most important point in AVM surgery is to find a plane between the nidus and the surrounding brain. Once the plane is found, it should be followed around the AVM nidus. The arterial feeders and dilated capillaries encountered should be coagulated first and the main draining vein should be preserved till the end. Feeder more than 1 mm should be occluded by coagulation and hemoclip. The AVM in eloquent area can also be removed based on the same principles except that plane should be made first in the adjacent noneloquent area and then followed in the eloquent area. The surgical strategies and management of complications will be presented by video clips.