Delayed Hemorrhage After Treatment of Brain Arteriovenous Malformations (AVMs)

Treatment of high-grade brain arteriovenous malformations using a hybrid operating room: A prospective single-arm study

BACKGROUND

Optimal treatment of patients with high Spetzler-Martin (S-M) grade brain arteriovenous malformations (BAVMs) remains controversial. Few studies have investigated outcomes in such patients treated in a hybrid operating room (hOR).

OBJECTIVE

To examine outcomes of one-stop hybrid BAVM treatment in patients with high-grade lesions.

METHODS

We prospectively enrolled patients with high-grade BAVMs (S-M grade ≥3) aged 18-65 years who underwent one-stop hybrid BAVM treatment at our hospital between October 2016 and March 2021. High-grade BAVM patients who underwent surgery from 2010 to 2016 served as historical controls.

RESULTS

Forty-one high-grade BAVM patients underwent one-stop hybrid treatment in a hOR. Sixty-one propensity score-matched patients comprised the historical control group. The groups did not significantly differ in patient and BAVM characteristics. Intraoperative angiography in four patients of the hOR group demonstrated residual nidus that required further immediate resection. Main procedural complications included hemorrhage, neurologic deficit, and seizure. In the historical control group, diffuse angioarchitecture and arteriovenous fistula were independent risk factors for incomplete resection.

CONCLUSIONS

One-stop hybrid BAVM treatment is safe and effective for removal of high-grade BAVMs, especially those with diffuse or complex angioarchitecture. Preoperative embolization can effectively reduce blood flow while preserving motor and language function. The combined application of functional magnetic resonance imaging, electrophysiological monitoring, and awake craniotomy can successfully avoid causing neurological injury.

Delayed hemorrhage following deep brain stimulation device placement in a patient with Parkinson’s disease and lupus anticoagulant syndrome: illustrative case

BACKGROUND

Treatment options for Parkinson’s disease (PD) include both medical and surgical approaches. Deep brain stimulation (DBS) is a surgical procedure that aims to improve motor symptomatology.

OBSERVATIONS

A 66-year-old White male with a 9-year history of PD presented to the neurosurgery clinic for DBS consideration. On the morning of scheduled surgery, preoperative laboratory test results revealed a prolonged prothrombin time of 50 seconds. Surgery was postponed, and further work-up revealed that the patient had a positive test result for lupus anticoagulant (LA). DBS implantation was performed 2 months later. The first stage of surgery was uneventful. The patient returned 1 week later for the second stage. Postoperatively, the patient exhibited a diminished level of consciousness. Computed tomography revealed left frontal intraparenchymal hemorrhage with surrounding edema, trace subarachnoid hemorrhage, intraventricular hemorrhage, and midline shift.

LESSONS

The authors suspect that the hemorrhage occurred secondary to venous infarct, because LA is associated with a paradoxically increased risk of thrombosis. Although there is no documented association between LA and acute or delayed hemorrhage, this case demonstrates a possible relationship in a patient following DBS placement. More research is needed to confirm an association with coexisting LA with PD and an increased hemorrhage risk in neurosurgical interventions.

Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation. Methods: Participants in the multicenter prospective clinical trial (NCT03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups. Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs. Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series

BACKGROUND

Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS.

OBSERVATIONS

Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women’s Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients.

LESSONS

This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.

Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study

BACKGROUND

Microsurgery (MS) and stereotactic radiosurgery (SRS) remain the preferred interventions for the curative treatment of brain arteriovenous malformations (AVM), but their relative efficacy remains incompletely defined.

OBJECTIVE

To compare the outcomes of MS to SRS for AVMs through a retrospective, matched cohort study.

METHODS

We evaluated institutional databases of AVM patients who underwent MS and SRS. MS-treated patients were matched, in a 1:1 ratio based on patient and AVM characteristics, to SRS-treated patients. Statistical analyses were performed to compare outcomes data between the 2 cohorts. The primary outcome was defined as AVM obliteration without a new permanent neurological deficit.

RESULTS

The matched MS and SRS cohorts were each comprised of 59 patients. Both radiological (85 vs 11 mo; P < .001) and clinical (92 vs 12 mo; P < .001) follow-up were significantly longer for the SRS cohort. The primary outcome was achieved in 69% of each cohort. The MS cohort had a significantly higher obliteration rate (98% vs 72%; P = .001), but also had a significantly higher rate of new permanent deficit (31% vs 10%; P = .011). The posttreatment hemorrhage rate was significantly higher for the SRS cohort (10% for SRS vs 0% for MS; P = .027). In subgroup analyses of ruptured and unruptured AVMs, no significant differences between the primary outcomes were observed.

CONCLUSION

For patients with comparable AVMs, MS and SRS afford similar rates of deficit-free obliteration. Nidal obliteration is more frequently achieved with MS, but this intervention also incurs a greater risk of new permanent neurological deficit.

In-room assessment of intravascular velocity from time-resolved rotational angiography in patients with arteriovenous malformation: a pilot study

Background

Time-resolved rotational angiography (t-RA) enables interventionists to better comprehend complex arteriovenous malformations (AVMs), thereby facilitating endovascular treatment. However, its use in evaluating hemodynamic changes has rarely been explored.

Objective

This study uses t-RA to estimate intravascular flow in patients with AVM to compare this with flow in the normal population.

Methods

Patients with available t-RA scans were prospectively categorized into one of three groups: hemorrhagic AVM, non-hemorrhagic AVM and control. Pulsatile time–density curves (TDCs) for C1, C6 and VOIMCA were used for amplitude and velocity estimation. C1 was at the cervical internal carotid artery (ICA), 2–3 cm below the carotid canal, C6 was at the paraclinoid segment of the ICA, and VOIMCA was at the junction of the first and second segment of the middle cerebral artery (MCA). A waveform amplitude ratio was defined as (peak − trough)/trough contrast intensity. VICA was defined as the distance between C6 and C1 divided by the time required for the wave to pass, and correspondingly, the average velocity of MCA (VMCA) was defined as the distance between C6 and VOIMCA divided by the duration for the same peak to travel from C6 and VOIMCA, AVM volume was estimated by MR angiography.

Results

Amplitude ratios AC1 and AC6, and average flow velocities VICA and VMCA were significantly larger in the non-hemorrhagic group than in the control group, while the hemorrhagic AVM group was not significantly different from the controls. VICA and VMCA showed moderate to good correlations with AVM volume (r=0.51 and 0.73, respectively). VMCA (33.0±9.1) was significantly lower than VICA (41.3±13.2) in the control group, but not in the two AVM groups.

Conclusion

TDC waveform propagation derived from t-RA can quantify hemodynamic differences between AVM and the control group. t-RA provides both real-time anatomic and hemodynamic evaluation, and can thus potentially improve the interventional workflow.

BrainPath-Mediated Resection of a Ruptured Subcortical Arteriovenous Malformation

BACKGROUND

Although tubular retractor systems have gained popularity for other indications, there have been few reports of their use for arteriovenous malformation (AVM) surgery. A patient was diagnosed with a ruptured 1.2-cm subcortical AVM after presenting with intracerebral hemorrhage in the right frontal lobe and anterior basal ganglia. The characteristics of this AVM made it amenable to resection using a tubular retractor.

OBJECTIVE

To demonstrate the feasibility and safety of AVM resection using a tubular retractor system.

METHODS

Resection of the ruptured 1.2-cm subcortical AVM was performed utilizing the BrainPathTM (NICO corp, Indianapolis, Indiana) tubular retractor system.

RESULTS

The BrainPathTM approach provided sufficient visualization and surgical freedom to permit successful AVM resection and hematoma evacuation. Postoperative imaging demonstrated near total hematoma removal and angiographic obliteration of the AVM. There were no complications, and the patient made an excellent recovery.

CONCLUSION

Tubular retractors warrant consideration for accessing small, deep, ruptured AVMs. The nuances of such systems and their role in AVM surgery are discussed.