combined neurovascular unit decided that adjunctive embolization wasindicated, this was performed preoperatively in either one or multiplestages at an earlier date than the date of surgery. Endovascular emboli-zation was performed intra-arterially via a transfemoral route and con-sisted of super-selective injection of
-butylcyanoacrylate in intendedvessels with the patient under general anesthesia .In every patient, postoperative angiography was performed immedi-ately after AVM surgery. Our protocol has been for direct return to theoperating room for immediate surgical re-exploration under strict bloodpressure control if residual AVM or early draining vein is identiﬁed onpostoperative angiography. After re-exploration, another immediateangiogram is performed.The radiographic studies, medical records, operative notes, and ofﬁcecharts were retrospectively reviewed as well as clinical data from aprospectively collected clinical AVM computer database. Spetzler–Martin grade was assigned to each AVM on the basis of size, venousdrainage, and eloquence of location as previously described . Clin-ical outcome was determined independently by a neurovascular nursepractioner who enters Glasgow Outcome Score  prospectively into theAVM computer database.
Therewere total sixpatients (1.8% ofpatients operatedwith intracranial AVMs) with residual lesions seen onpostoperative angiography following surgical resectionof their intracranial AVMs. Table 1 summarizes the clin-ical, demographic, anatomic, and radiographic details of the six patients. All residual lesions were small (
1cm).Initial presentation was: hemorrhage 4, and seizures 2.Initial management of hematomas was conservative inone patient (Patient 6 in Table 1), external ventriculardrainage with eventual ventriculoperitoneal shunt place-ment in two patients (Patients 2 and 3), and endovascularcoiling of feeding pedicle aneurysm and external ventri-cular drainage without eventual ventriculoperitonealshunting in one patient (Patient 5). No patient of thesix noted required surgical evacuation of hematoma.Preoperative embolization was performed in fourpatients. Four AVMs were supratentorial, two wereinfratentorial. AVM sizes were one small (
3cm), threemedium (3–6cm), and two large (
6cm). Deep venousdrainage was present in four AVMs. Three AVMs werein eloquent locations. Spetzler–Martin grades were II: 2,III: 2, and V: 2.All six patients were surgically re-explored immedi-ately. All six patients had complete obliteration on fol-lowup angiography (100%); two patients required twore-exploration procedures (Patients 4 and 6). Patient 4had a tiny early draining vein which persisted on angio-gram after immediate re-exploration and underwent asecond re-exploration, this time with placement of aCosman-Roberts-Wells stereotactic head frame duringangiography, for stereotactic localization of the lesionfor the second re-exploration procedure. He had com-plete obliteration of the lesion after this procedure.Patient 6 had a small residual lesion deep to the resec-tion cavity seen on immediate postoperative angio-graphy with persistent residual after immediatere-exploration. A second re-exploration was performedtwo weeks later for complete obliteration of the AVM.Four patients were neurologically intact preopera-tively and remained neurologically intact postopera-tively (Patients 1, 2, 4, 5, in Table 1). One patient wasdependent with a left hemiparesis preoperatively from asevere intracerebral hemorrhage from her right motorstrip AVM, and did not have a change in her neurologiccondition postoperatively (Patient 6). One patient with alarge right occipito-temporal-parietal AVM required re-operation for a residual lesion. The patient incurred rightposterior cerebral artery (PCA) and superior cerebellarartery (SCA) infarcts with accompanying swellingrequiring posterior fossa decompression (Patient 3). Hehad a left visual ﬁeld deﬁcit preoperatively, but wasdependent and with a left hemiparesis after his infarcts.This was the one operative complication among the sixpatients.Overall clinical outcome was excellent (GOS 5) infour patients, fair (GOS 3) in two patients. There wereno poor outcomes or deaths.
Case 1 (Patient 1). A 31 year-old woman presentedwith her ﬁrst generalized tonic-clonic seizure. She wasneurologically intact and placed on carbamazepine. Shewas found to have a 3cm right posterior temporal AVMfed predominantly by three large right middle cerebralartery (MCA) opercular temporal branches with drainageto the vein of Trolard and the vein of Labbe (Fig. 1).Single-stage endovascular embolization with
-butylcya-noacrylate was performed in three pedicles with 70%reduction in ﬂow to the AVM. Two days later, she under-went right temporal craniotomy and surgical resection.Immediate postoperative angiography revealed a smallremnant of AVM fed by the right anterior choroidalartery and a branch off of the angular artery. Immediatesurgical re-exploration was performed for completeobliteration of the AVM. She was neurologically intactand was discharged home on postoperative day three.
The actual incidence of incomplete surgical resec-tion of AVMs is not well-documented in the literature.
B. L. Hoh