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Published by bodeadumitru9261
Incidence of residual intracranial AVMs after surgical resection
and efficacy of immediate surgical re-exploration
Incidence of residual intracranial AVMs after surgical resection
and efficacy of immediate surgical re-exploration

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Published by: bodeadumitru9261 on May 14, 2010
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Acta Neurochir (Wien) (2004) 146: 1–7DOI 10.1007/s00701-003-0164-5
Clinical Article
Incidence of residual intracranial AVMs after surgical resectionand efficacy of immediate surgical re-exploration
B. L. Hoh
1
;
2
, B. S. Carter
1
,
and
C. S. Ogilvy
1
1
Cerebrovascular Surgery, Neurosurgical Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
2
Endovascular Neurosurgery and Interventional Neuroradiology, Massachusetts General Hospital, HarvardMedical School, Boston, MassachusettsPublished online December 9, 2003
#
Springer-Verlag 2003
Summary
 Background.
The true incidence of residual lesions after surgicalresection of AVMs is not well documented in the literature. Partialsurgical resection is thought to not confer any improvement over thenatural history risk of hemorrhage of AVMs, and in certain cases mayactually increase the risk of hemorrhage. Over the past 11 years, we haveadopted a policy of immediate postoperative angiography with immedi-ate surgical re-exploration if a residual lesion is seen. The purpose of thepresent study was to review our experience to determine the incidence of residual lesions and subsequent outcome.
 Methods.
From June 1991 to June 2002, 324 patients underwentcraniotomy and surgical AVM resection. As per protocol, all patientsunderwent immediate postoperative angiography. We have a protocol forimmediate surgical re-exploration if a residual lesion is seen on post-operative angiographic exam.
Findings.
There were total six patients (1.8% of patients operated withintracranial AVMs) with residual lesions on postoperative angiography.All six patients underwent immediate surgical re-exploration with com-plete 100% obliteration; two patients required two re-exploration proce-dures. There was one operative complication: posterior cerebral arteryand superior cerebellar artery infarcts after re-exploration of residuallesion after surgical resection of a large occipito-temperal-parietal AVM.There were no other morbidities and no mortalities.
Conclusions.
The incidence of residual lesions seen on postoperativeangiography after AVM surgery at an experienced center is 1.8%.Because of the potential imminent danger of hemorrhage from a residuallesion, we recommend a policy of immediate postoperative angiography(or intraoperative angiography if image quality is satisfactory) for allAVM surgery and early surgicalre-exploration ifa residual lesion is seen.
Keywords:
Angiography; AVM; embolization; hemorrhage; reopera-tion; surgery.
Introduction
The true incidence of residual lesions after surgicalresection of intracranial arteriovenous malformations(AVMs) is not well documented in the literature. Partialsurgical resection does not confer any improvement overthe natural history risk of hemorrhage of AVMs, and incertain cases may actually increase the risk of hemo-rrhage [3, 14]. Residual AVMs or residual early drainingveins can remain after surgical resection, unrecognizedat the time of operation, only to be seen on postopera-tive angiography. Immediate postoperative angiography(or intraoperative angiography if available withhigh-standard image quality) is thus critical to assessfor residual AVM and can facilitate prompt surgicalattention.Over the past 11 years, we have obtained immediatepostoperative angiography for all AVMs with a protocolfor immediate surgical re-exploration if any residuallesion or remaining early draining vein is found. Wereviewed our surgical experience to determine the trueincidence of residual intracranial AVMs after operativeresection. We also evaluated the efficacy and outcomeusing a protocol for immediate surgical re-explorationfor residual lesions.
Methods
From June 1991 to June 2002, 324 patients underwent craniotomy andsurgical resection of intracranial AVMs at the Massachusetts GeneralHospital. Our combined neurovascular unit of neurosurgeons, interven-tional neuroradiologists, radiation oncologists, and neurologists jointlydecided upon surgical resection with or without preoperative adjunctiveembolization as the optimal treatment strategy in these patients.Surgical technique was performed according to modern principles of microsurgical AVM resection under general anesthesia [7]. When our
 
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 
n
-butylcyanoacrylate in intendedvessels with the patient under general anesthesia [4].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 [16]. Clin-ical outcome was determined independently by a neurovascular nursepractioner who enters Glasgow Outcome Score [8] prospectively into theAVM computer database.
Results
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.
Illustrative cases
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
n
-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.
Discussion
The actual incidence of incomplete surgical resec-tion of AVMs is not well-documented in the literature.
2
B. L. Hoh
et al.
 
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Incidence of residual intracranial AVMs after surgical resection and efficacy of immediate surgical re-exploration
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