|
1
|
Orscelik A, Musmar B, Matsukawa H, Ismail M, Elawady SS, Assad S, Cunningham C, Sowlat MM, Spiotta AM. Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2025; 96:18-28. [PMID: 38912816 DOI: 10.1227/neu.0000000000003043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT). METHOD Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision. RESULTS MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01). CONCLUSION This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.
Collapse
Affiliation(s)
- Atakan Orscelik
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya , Japan
| | - Mustafa Ismail
- College of Medicine, University of Baghdad, Baghdad , Iraq
| | - Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Salman Assad
- Department of Neurology, University of Nebraska Medical Center, Omaha , Nebraska , USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Mohamed Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| |
Collapse
|
|
2
|
Gutierrez Pineda F, Quiceno E, Suarez Marin MM, Londoño Ocampo FJ. Early versus Delayed Surgical Management of Ruptured Arteriovenous Brain Malformations in a Tertiary Referral Center in Colombia, South America. World Neurosurg 2024:S1878-8750(24)01440-2. [PMID: 39168243 DOI: 10.1016/j.wneu.2024.08.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Surgical timing after rupture of brain arteriovenous malformations (AVMs) is controversial. There is scarce literature on AVM surgical outcomes from developing countries. This study aims to determine if there is a difference between early and delayed surgical resection for patients with ruptured brain AVMs. METHODS This single-center retrospective review included patients who underwent surgical resection for ruptured brain AVMs in Colombia. Patients were stratified by the timing of surgical intervention relative to the rupture into early (≤72 hours of bleeding) and delayed (>72 hours) resection. Continuous variables were analyzed using an independent t-test, and dichotomous variables were analyzed using a χ2 test. A linear regression analysis was performed with the final mRankin score at 2 years as the dependent variable; P < 0.05 was considered significant. RESULTS Thirty-one patients were identified. The early treatment group included 14 (45.2%) patients, and the delayed group included 17 (54.8%) patients. The mean (SD) length of time between AVM rupture and surgical resection was 1.6 ± 1.2 days and 12.4 ± 8.4 days, respectively (P < 0.001). There were no differences regarding demographics, perioperative variables, and postoperative outcomes between groups. In the linear regression analysis, the only variable that had a significant association with the final mRankin score was the initial Glasgow Coma Scale, which had a β coefficient of -0.6341 (95% confidence interval: -0.41,-0.017, P = 0.035). CONCLUSIONS In this case series of 31 patients from a developing country, there were no differences in clinical outcomes at the final follow-up between acute and delayed surgical interventions for ruptured AVMs. The most important factor associated with the final outcomes was the initial Glasgow Coma Scale.
Collapse
Affiliation(s)
- Felipe Gutierrez Pineda
- Department of Neurosurgery, Universidad de Antioquia, School of Medicine, Medellin, Colombia; Department of Neurosurgery, Instituto Neurologico de Colombia, Medellin, Colombia
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA; Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York, USA.
| | - Mauro Marcelo Suarez Marin
- Department of Neurosurgery, Universidad de Antioquia, School of Medicine, Medellin, Colombia; Department of Neurosurgery, Instituto Neurologico de Colombia, Medellin, Colombia
| | - Francisco Javier Londoño Ocampo
- Department of Neurosurgery, Universidad de Antioquia, School of Medicine, Medellin, Colombia; Department of Neurosurgery, Hospital Pablo Tobon Uribe, Medellin, Colombia
| |
Collapse
|
|
3
|
Zhang Y, Chen Y, Han H, Ma L, Li R, Li Z, Yan D, Zhang H, Yuan K, Wang K, Zhao Y, Jin W, Jin H, Meng X, Li R, Lin F, Hao Q, Wang H, Ye X, Kang S, Gao D, Sun S, Liu A, Li Y, Chen X, Wang S, Zhao Y. Timing of microsurgical resection for ruptured brain arteriovenous malformations: a propensity score-matched analysis using prospective single-center registry data. J Neurosurg 2024; 140:164-171. [PMID: 37439476 DOI: 10.3171/2023.5.jns222666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 05/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE The optimal microsurgical timing in ruptured brain arteriovenous malformations (AVMs) is not well understood and is surrounded by controversy. This study aimed to elucidate the impacts of microsurgical resection timing on clinical outcomes. METHODS The authors retrieved and reviewed the records on all ruptured AVMs treated at their institution and registered in a nationwide multicenter prospective collaboration registry between August 2011 and August 2021. Patients were dichotomized into an early resection group (≤ 30 days from the last hemorrhagic stroke) and a delayed resection group (> 30 days after the last hemorrhagic stroke). Propensity score-matched analysis was used to compare long-term outcomes. The primary outcome was neurological status as assessed using the modified Rankin Scale (mRS). The secondary outcomes were complete obliteration rate, postoperative seizure, and postoperative hemorrhage. RESULTS Of the 3649 consecutive AVMs treated at the authors' institution, a total of 558 ruptured AVMs were microsurgically resected and had long-term follow-up. After propensity score matching, 390 ruptured AVMs (195 pairs) were included in the comparison of outcomes. The mean (± standard deviation) clinical follow-up duration was 4.93 ± 2.94 years in the early resection group and 5.61 ± 2.56 years in the delayed resection group. Finally, as regards the distribution of mRS scores, short-term neurological outcomes were better in the delayed resection group (risk difference [RD] 0.3%, 95% CI -0.1% to 0.6%, p = 0.010), whereas long-term neurological outcomes were similar between the two groups (RD 0.0%, 95% CI -0.2% to 0.2%, p = 0.906). Long-term favorable neurological outcomes (early vs delayed: 90.8% vs 90.3%, p > 0.999; RD 0.5%, 95% CI -5.8% to 6.9%; RR 1.01, 95% CI 0.94-1.07) and long-term disability (9.2% vs 9.7%, p > 0.999; RD -0.5%, 95% CI -6.9% to 5.8%; RR 0.95, 95% CI 0.51-1.75) were also similar between these groups. In terms of secondary outcomes, postoperative seizure (early vs delayed: 8.7% vs 5.6%, p = 0.239; RD 3.1%, 95% CI -2.6% to 8.8%; RR 1.55, 95% CI 0.74-3.22), postoperative hemorrhage (1.0% vs 1.0%, p > 0.999; RD 0.0%, 95% CI -3.1% to 3.1%; RR 1.00, 95% CI 0.14-7.04), and hospitalization time (16.4 ± 8.5 vs 19.1 ± 7.9 days, p = 0.793) were similar between the two groups, whereas early resection had a lower complete obliteration rate (91.3% vs 99.0%, p = 0.001; RD -7.7%, 95% CI -12.9% to 3.1%; RR 0.92, 95% CI 0.88-0.97). CONCLUSIONS Early and delayed resection of ruptured AVMs had similar long-term neurological outcomes. Delayed resection can lead to a higher complete obliteration rate, although the risk of rerupture during the resection waiting period should be vigilantly monitored.
Collapse
Affiliation(s)
- Yukun Zhang
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
- 3Department of Neurosurgery, Peking University International Hospital, Beijing
| | - Yu Chen
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Heze Han
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Li Ma
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Ruinan Li
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Zhipeng Li
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Debin Yan
- 4Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi
| | - Haibin Zhang
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Kexin Yuan
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Ke Wang
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Yang Zhao
- 3Department of Neurosurgery, Peking University International Hospital, Beijing
| | - Weitao Jin
- 3Department of Neurosurgery, Peking University International Hospital, Beijing
| | - Hengwei Jin
- 5Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Xiangyu Meng
- 6Department of Neurosurgery, The First Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, Hebei; and
| | - Runting Li
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Fa Lin
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Qiang Hao
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Hao Wang
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Xun Ye
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Shuai Kang
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Dezhi Gao
- 7Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- 7Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- 7Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- 5Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing
| | - Xiaolin Chen
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Shuo Wang
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| | - Yuanli Zhao
- Departments of1Neurosurgery and
- 2China National Clinical Research Center for Neurological Diseases, Beijing
| |
Collapse
|
|
4
|
Baranoski JF, Koester SW, Catapano JS, Garcia JH, Pacult MA, Hoglund BK, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Rutledge C, Srinivasan VM, Graffeo CS, Ducruet AF, Albuquerque FC, Lawton MT. Early Treatment of Ruptured Cerebral Arteriovenous Malformations: Analysis of Neurological Outcomes and Health Care Costs. Neurosurgery 2024; 94:212-216. [PMID: 37665224 DOI: 10.1227/neu.0000000000002641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND The timing of surgical resection is controversial when managing ruptured arteriovenous malformations (AVMs) and varies considerably among centers. OBJECTIVE To retrospectively analyze clinical outcomes and hospital costs associated with delayed treatment in a ruptured cerebral AVM patient cohort. METHODS Patients undergoing surgical treatment for a ruptured cerebral AVM (January 1, 2015-December 31, 2020) were retrospectively analyzed. Patients who underwent emergent treatment of a ruptured AVM because of acute herniation were excluded, as were those treated >180 days after rupture. Patients were stratified by the timing of surgical intervention relative to AVM rupture into early (postbleed days 1-20) and delayed (postbleed days 21-180) treatment cohorts. RESULTS Eighty-seven patients were identified. The early treatment cohort comprised 75 (86%) patients. The mean (SD) length of time between AVM rupture and surgical resection was 5 (5) days in the early cohort and 73 (60) days in the delayed cohort ( P < .001). The cohorts did not differ with respect to patient demographics, AVM size, Spetzler-Martin grade, frequency of preoperative embolization, or severity of clinical presentation ( P ≥ .15). Follow-up neurological status was equivalent between the cohorts ( P = .65). The associated mean health care costs were higher in the delayed treatment cohort ($241 597 [$99 363]) than in the early treatment cohort ($133 989 [$110 947]) ( P = .02). After adjustment for length of stay, each day of delayed treatment increased cost by a mean of $2465 (95% CI = $967-$3964, P = .002). CONCLUSION Early treatment of ruptured AVMs was associated with significantly lower health care costs than delayed treatment, but surgical and neurological outcomes were equivalent.
Collapse
Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix , Arizona , USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
5
|
Bintang AK, Bahar A, Akbar M, Soraya GV, Gunawan A, Hammado N, Rachman ME, Ulhaq ZS. Delayed versus immediate intervention of ruptured brain arteriovenous malformations: A case report. World J Clin Cases 2023; 11:1992-2001. [PMID: 36998967 PMCID: PMC10044944 DOI: 10.12998/wjcc.v11.i9.1992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/07/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) remains one of the most prevalent causes of intracranial hemorrhage and stroke-like syndromes in the young adult population. Although it has been agreed upon that definitive treatment using either single or multi-modal approach is warranted for successful bAVM management, much debate still revolves regarding the optimal timing of definitive treatment.
CASE SUMMARY In this report, we present a case of delayed, definitive endovascular treatment for ruptured bAVM in a 21-year-old female, 3 mo post-ictus. The bAVM, with a left pericallosal feeding artery and cortical draining veins, was successfully obliterated through embolization using the Onyx 18. On follow-up the patient has recommenced her daily activities and experiences only mild occasional headaches with mild motor deficits. The report leads to our review on an important issue regarding the optimal timing of ruptured bAVM definitive management and bring forward the current evidence available on delayed vs immediate definitive bAVM intervention. We also highlight current issues that need to be addressed for clearer guidelines on definitive therapy initiation.
CONCLUSION Current treatment paradigms of ruptured bAVM remains elusive, with substantial heterogeneity in the current literature. A consensus on the definition of “acute” vs “delayed”, management goal, follow-up length and outcome parameters are required to support formation of a clear paradigm.
Collapse
Affiliation(s)
| | - Ashari Bahar
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Muhammad Akbar
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Gita Vita Soraya
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Department of Biochemistry, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia
| | - Anthony Gunawan
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
| | - Nurussyariah Hammado
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Faculty of Health and Sport Science, State University of Makassar, Makassar 90222, Indonesia
| | - Mochammad Erwin Rachman
- Department of Neurology, Hasanuddin University, Makassar 90245, Indonesia
- Faculty of Medicine, Muslim University of Indonesia, Makassar 90231, Indonesia
| | - Zulvikar Syambani Ulhaq
- Research Center for Preclinical and Clinical Medicine, National Research and Innovation Agency Republic of Indonesia, Cibinong 16911, Indonesia
- Laboratory of Developmental Disorders and Toxicology, Kyushu University, Fukuoka 8190395, Japan
- Department of Biomedical Science, Faculty of Medicine and Health Sciences, Maulana Malik Ibrahim State Islamic University, Malang 65144, Indonesia
| |
Collapse
|
|
6
|
Sen RD, Abecassis IJ, Barber J, Levitt MR, Kim LJ, Ellenbogen RG, Sekhar LN. Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations. J Neurosurg 2022; 137:321-328. [PMID: 34861649 DOI: 10.3171/2021.8.jns211075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.
Collapse
Affiliation(s)
- Rajeev D Sen
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Jason Barber
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Michael R Levitt
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 3Department of Radiology, University of Washington, Seattle, Washington
- 4Department of Mechanical Engineering, University of Washington, Seattle, Washington; and
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Louis J Kim
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 3Department of Radiology, University of Washington, Seattle, Washington
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Richard G Ellenbogen
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
- 5Stroke & Applied Neurosciences Center, University of Washington, Seattle, Washington
| | - Laligam N Sekhar
- 1Department of Neurological Surgery, University of Washington, Seattle, Washington
| |
Collapse
|
|
7
|
Decompressive hemicraniectomies as damage control for ruptured intracranial arteriovenous malformations: A case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
|
8
|
Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
Collapse
Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| |
Collapse
|
|
9
|
Karki P, Sharma GR, Joshi S, Paudel P, Shah DB. Retrospective Study and Outcome Predictor after Microsurgical Resection of Cerebral Arteriovenous Malformations in Nepal. Asian J Neurosurg 2021; 16:355-362. [PMID: 34268164 PMCID: PMC8244694 DOI: 10.4103/ajns.ajns_509_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: The purpose of this study is to assess demographic, clinical, and morphological characteristics of patients with brain arteriovenous malformations (bAVMs). The relation of outcome using modified Ranklin Scale (mRS) at time of discharge, early and last follow ups with respect to various factors. Materials and Methods: Demographic data, arteriovenous malformation characteristics, and treatment outcomes were evaluated in 43 bAVMs treated with microsurgery between 2009 and 2019. For this series, 43 patients were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades (SMG) I/II, III, IV/V and III–V were performed. The mRS was used to assess functional outcomes. Results: Overall, mean age at diagnosis was 33 years (standard deviation = 19). Transient deficit, mRS deterioration and impaired functional outcome occurred less frequently in SMG I–II patients compared with Grade III–V patients combined (29% vs. 32% respectively, P = 0.00). All patients with SMG Grade I, Supplemented SMG Grade 2, 3, 4 and 6 had a mRS score of 2 or less at the last follow-up. Age was the only significant predictor of overall outcome after bAVM surgery on Chi-square test (P = 0.046), i.e: all patients <20 years had mRS score of 2 or less on last follow-up. Unfavorable outcome (mRS score of 3 or more than 3) level increased with higher grades in SMG on long term follow-up. Conclusion: The results of our case series of bAVM with SMG Grade I and Suplemented Grade 2, 3, 4 and even higher grade i.e., 6 can have excellent overall outcome after microsurgical resection. Association of factors which increases the grading system of bAVM like eloquence, deep venous drainage and increasing sizes did not correlate with the predicted unfavorable outcomes, whereas age of patients was a predictor of overall outcome. Although the small sample size of this study is a limitation, age of patient plays important role on the overall outcome.
Collapse
Affiliation(s)
- Prasanna Karki
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Gopal Raman Sharma
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Sumit Joshi
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Prakash Paudel
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Damber Bikram Shah
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| |
Collapse
|
|
10
|
Di Bartolomeo A, Scafa AK, Giugliano M, Dugoni DE, Ruggeri AG, Delfini R. Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases. J Neurosci Rural Pract 2020; 12:4-11. [PMID: 33551615 PMCID: PMC7857959 DOI: 10.1055/s-0040-1716792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.
Collapse
Affiliation(s)
- Alessandro Di Bartolomeo
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Anthony Kevin Scafa
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Marco Giugliano
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Demo Eugenio Dugoni
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Andrea Gennaro Ruggeri
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto Delfini
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
|
11
|
Jin H, Lenck S, Krings T, Agid R, Fang Y, Li Y, Kostynskyy A, Tymianski M, Pereira VM, Radovanovic I. Interval angioarchitectural evolution of brain arteriovenous malformations following rupture. J Neurosurg 2019; 131:96-103. [PMID: 30052159 DOI: 10.3171/2018.2.jns18128] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/23/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to describe changes in the angioarchitecture of brain arteriovenous malformations (bAVMs) between acute and delayed cerebral digital subtraction angiography (DSA) obtained after hemorrhage, and to examine bAVM characteristics predicting change. METHODS This is a retrospective study of a prospective institutional bAVM database. The authors included all patients with ruptured bAVMs who had DSA in both acute and delayed phases, with no interval treatment of their bAVM, between January 2000 and April 2017. The authors evaluated the existence or absence of angioarchitectural changes. Demographic data, radiological characteristics of hemorrhages, and angioarchitectural features of the bAVMs of the two patients' groups were analyzed. Univariate and multivariate logistic analyses were performed to identify predictors of angioarchitectural change. RESULTS A total of 42 patients were included in the series. Seventeen (40.5%) patients had angioarchitectural changes including bAVM only visible on the delayed DSA study (n = 8), spontaneous thrombosis of the AVM (n = 3), or alteration of the size or the opacification of the nidus (n = 6). The factors associated with angioarchitectural changes were a small nidus (3.8 ± 7.9 ml vs 6.1 ± 9.5 ml, p = 0.046), a superficial location (94.1% vs 5.9%, p = 0.016), and a single superficial draining vein (58.8% vs 24.0%, p = 0.029). CONCLUSIONS Angioarchitectural changes can be seen in 40% of ruptured bAVMs between the acute- and delayed-phase DSA. A small nidus, a superficial location, and a single superficial draining vein were statistically associated with the occurrence of angioarchitectural changes. These changes included either enlargement or spontaneous occlusion of the bAVM, as well as subsequent diagnosis of a bAVM following an initial negative DSA study.
Collapse
Affiliation(s)
- Hengwei Jin
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 2Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Stephanie Lenck
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Timo Krings
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ronit Agid
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yibin Fang
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 4Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Youxiang Li
- 2Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 3Beijing Engineering Research Center for Interventional Neuroradiology, Beijing, China
| | - Alex Kostynskyy
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael Tymianski
- 5Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; and
- 6Krembil Neuroscience Center, University Health Network, Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- 1Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 5Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; and
| | - Ivan Radovanovic
- 5Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada; and
- 6Krembil Neuroscience Center, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
|
12
|
Dinc N, Won SY, Brawanski N, Eibach M, Quick-Weller J, Konczalla J, Berkefeld J, Seifert V, Marquardt G. Differences in bleeding patterns and outcome after intracerebral hemorrhage due to vascular malformations. PLoS One 2019; 14:e0217017. [PMID: 31120937 PMCID: PMC6532871 DOI: 10.1371/journal.pone.0217017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atypical intracerebral hemorrhage is a common form of primary manifestation of vascular malformations. OBJECTIVE The aim of the present study is to determine clues to the cause of bleeding according to hemorrhage pattern (lobar, basal ganglia, infratentorial). METHODS We retrospectively evaluated 343 consecutive neurosurgical patients with intracerebral hemorrhage (ICH), who were admitted to our neurosurgical department between 2006 and 2016. The study cohort includes only neurosurgical patients. Patients who underwent treatment by neurologists are not represented in this study. We assessed location of hemorrhage, hematoma volumes to rule out differences and predicitve variables for final outcome. RESULTS In 171 cases (49.9%) vascular malformations, such as arteriovenous malformations (AVMs), cavernomas, dural fistulas and aneurysms were the cause of bleeding. 172 (50.1%) patients suffered from an intracerebral hemorrhage due to amyloid angiopathy or long standing hypertension. In patients with infratentorial hemorrhage a malformation was more frequently detected as in patients with supratentorial hemorrhage (36% vs. 16%, OR 2.9 [1.8;4.9], p<0.001). Among the malformations AVMs were most common (81%). Hematoma expansion was smaller in vascular malformation than non-malformation caused bleeding (24.1 cm3 vs. 64.8 cm3, OR 0.5 [0.4;0.7], p < 0.001,). In 6 (2.1%) cases diagnosis remained unclear. Final outcome was more favorable in patients with vascular malformations (63% vs. 12%, OR 12.8 [4.5;36.2], p<0.001). CONCLUSION Localization and bleeding patterns are predictive factors for origin of the hemorrhage. These predictive factors should quickly lead to appropriate vascular diagnostic measures. However, due to the inclusion criteria the validity of the study is limited and multicentre studies with further testing in general ICH patients are required.
Collapse
Affiliation(s)
- Nazife Dinc
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
- * E-mail:
| | - Sae-Yeon Won
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Nina Brawanski
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Michael Eibach
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | | | - Jürgen Konczalla
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Joachim Berkefeld
- Department of Neuroradiology, Goethe University Hospital, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| | - Gerhard Marquardt
- Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany
| |
Collapse
|
|
13
|
Dinc N, Won SY, Quick-Weller J, Berkefeld J, Seifert V, Marquardt G. Prognostic variables and outcome in relation to different bleeding patterns in arteriovenous malformations. Neurosurg Rev 2019; 42:731-736. [DOI: 10.1007/s10143-019-01091-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/12/2019] [Accepted: 02/25/2019] [Indexed: 12/27/2022]
|
|
14
|
Choque-Velasquez J, Resendiz-Nieves J, Colasanti R, Collan J, Hernesniemi J. Microsurgical Management of Vascular Malformations of the Pineal Region. World Neurosurg 2018; 117:e669-e678. [DOI: 10.1016/j.wneu.2018.06.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
|
|
15
|
Hafez A, Oulasvirta E, Koroknay-Pál P, Niemelä M, Hernesniemi J, Laakso A. Timing of surgery for ruptured supratentorial arteriovenous malformations. Acta Neurochir (Wien) 2017; 159:2103-2112. [PMID: 28894970 DOI: 10.1007/s00701-017-3315-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/28/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are conflicting opinions regarding the optimal waiting time to perform surgery after rupture of supratentorial arteriovenous malformations (AVMs) to achieve the best possible outcome. OBJECTIVE To analyze factors influencing outcomes for ruptured supratentorial AVMs after surgery, paying particular attention to the timing of the surgery. METHODS We retrospectively investigated 59 patients admitted to our center between 2000 and 2014 for surgical treatment of ruptured supratentorial AVMs. We evaluated the effect of timing of surgery and other variables on the outcome at 2-4 months (early outcome), at 12 months (intermediate outcome) after surgery, and at final follow-up at the end of 2016 (late outcome). RESULTS Age over 40 years (OR 18.4; 95% CI 1.9-172.1; p = 0.011), high Hunt and Hess grade (4 or 5) before surgery (OR 13.5; 95% CI 2.1-89.2; p = 0.007), hydrocephalus on admission (OR 12.9; 95% CI 1.8-94.4; p = 0.011), and over 400 cm3 bleeding during surgery (OR 11.5; 95% CI 1.5-86.6; p = 0.017) were associated with an unfavorable early outcome. Age over 40 years (OR 62.8; 95% CI 2.6-1524.9; p = 0.011), associated aneurysms (OR 34.7; 95% CI 1.4-829.9; p = 0.029), high Hunt and Hess grade before surgery (OR 29.2; 95% CI 2.6-332.6; p = 0.007), and over 400 cm3 bleeding during surgery (OR 35.3; 95% CI 1.7-748.7; p = 0.022) were associated with an unfavorable intermediate outcome. Associated aneurysms (OR 8.2; 95% CI 1.2-55.7; p = 0.031), high Hunt and Hess grade before surgery (OR 5.7; 95% CI 1.3-24.3; p = 0.019), and over 400 cm3 bleeding during surgery (OR 5.8; 95% CI 1.2-27.3; p = 0.027) were associated with an unfavorable outcome at last follow-up. Elapsed time between rupture and surgery did not affect early or final outcome. CONCLUSIONS Early surgery in patients with ruptured supratentorial arteriovenous malformation is feasible strategy, with late results comparable to those achieved with delayed surgery. Many other factors than timing of surgery play significant roles in long-term outcomes for surgically treated ruptured supratentorial AVMs.
Collapse
Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland.
| | - Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland
| |
Collapse
|
|
16
|
Beecher JS, Lyon K, Ban VS, Vance A, McDougall CM, Whitworth LA, White JA, Samson D, Batjer HH, Welch BG. Delayed treatment of ruptured brain AVMs: is it ok to wait? J Neurosurg 2017; 128:999-1005. [PMID: 28686111 DOI: 10.3171/2017.1.jns16745] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite a hemorrhagic presentation, many patients with arteriovenous malformations (AVMs) do not require emergency resection. The timing of definitive management is not standardized in the cerebrovascular community. This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation. The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage. METHODS Patients presenting to the authors' institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis. Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM, prior treatment of AVM at another institution, or treatment of lesions within 4 weeks for other reasons (subacute surgery). The primary outcome measure was time from initial hemorrhage to treatment failure (defined as rehemorrhage or neurological decline as a direct result of the AVM). Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed. RESULTS Of 102 ruptured AVMs in 102 patients meeting inclusion criteria, 7 (6.9%) failed the treatment paradigm. Six patients (5.8%) had a new hemorrhage within a median of 248 days (interquartile range 33-1364 days). The total "at risk" period was 18,740 patient-days, yielding a rehemorrhage rate of 11.5% per patient-year, or 0.96% per patient-month. Twelve (11.8%) of 102 patients were found to have an associated aneurysm. In this group there was a single (8.3%) new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured, yielding a rehemorrhage risk of 11.4% per patient-month. CONCLUSIONS It is the authors' practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM. The present data are useful in that the findings quantify the risk of the authors' treatment strategy. These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low (< 1%) risk of rehemorrhage. The authors modified the treatment paradigm when a high-risk feature, such as an associated intracranial aneurysm, was identified.
Collapse
|
|
17
|
Barone DG, Marcus HJ, Guilfoyle MR, Higgins JNP, Antoun N, Santarius T, Trivedi RA, Kirollos RW. Clinical Experience and Results of Microsurgical Resection of Arterioveonous Malformation in the Presence of Space-Occupying Intracerebral Hematoma. Neurosurgery 2017; 81:75-86. [DOI: 10.1093/neuros/nyx003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/14/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Management of ruptured arteriovenous malformations (AVMs) with a mass-producing intracerebral hematoma (ICH) represents a surgical dilemma.
OBJECTIVE: To evaluate the clinical outcome and obliteration rates of microsurgical resection of AVM when performed concomitantly with evacuation of an associated space-occupying ICH.
METHODS: Data of patients with AVM were collected prospectively. Cases were identified in which an AVM was resected and an associated space-occupying ICH was evacuated at the same time, and divided into “group 1,” in which the surgery was performed acutely within 48 h of presentation (secondary to elevated intracranial pressure); and “group 2,” in which selected patients were operated upon in the presence of a liquefying ICH in the “subacute” stage. Clinical outcomes were assessed using the modified Rankin Scale, with a score of 0 to 2 considered a good outcome. Obliteration rates were assessed using postoperative angiography.
RESULTS: From 2001 to 2015, 131 patients underwent microsurgical resection of an AVM, of which 65 cases were included. In “group 1” (n = 21; Spetzler-Ponce class A = 13, class B = 5, and class C = 3), 11 of 21 (52%) had a good outcome and in 18 of 19 (95%) of those who had a postoperative angiogram the AVMs were completely obliterated. In “group 2” (n = 44; Spetzler-Ponce class A = 33, class B = 9, and class C = 2), 31 of 44 (93%) had a good outcome and 42 of 44 (95%) were obliterated with a single procedure. For supratentorial AVMs, the ICH cavity was utilized to provide an operative trajectory to a deep AVM in 11 cases, and in 26 cases the ICH cavity was deep to the AVM and hence facilitated the deep dissection of the nidus.
CONCLUSION: In selected patients the presence of a liquefying ICH cavity may facilitate the resection of AVMs when performed in the subacute stage resulting in a good neurological outcome and high obliteration rate.
Collapse
Affiliation(s)
| | - Hani J. Marcus
- Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK
| | | | | | - Nagui Antoun
- Department of Neuroradiology, Adden-brooke's Hospital, Cambridge, UK
| | - Thomas Santarius
- Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK
| | - Rikin A. Trivedi
- Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK
| | | |
Collapse
|
|
18
|
Michael T. Lawton: Seven AVMs: tenets and techniques for resection. Acta Neurochir (Wien) 2014. [DOI: 10.1007/s00701-014-2153-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
|
19
|
Abstract
Intracranial arteriovenous malformations (AVMs) are a common cause of stroke in younger patients, and often present as intracerebral hemorrhages (ICH), associated with 10 % to 30 % mortality. Patients who present with a hemorrhage from an AVM should be initially stabilized according to acute management guidelines for ICH. The characteristics of a lesion including its size, location in eloquent tissue, and high-risk features will influence risk of rupture, prognosis, as well as help guide management decisions. Given that rupture is associated with an increased risk of 6 % re-rupture in the year following the initial hemorrhage, versus 1 % to 3 % predicted annual risk in non-ruptured lesions only, definitive treatment is encouraged after ICH stabilization. A rest period of 2 to 6 weeks after hemorrhage is recommended before definitive treatment to avoid disrupting friable parenchyma and the hematoma. Treatment may consist of endovascular embolization, surgical resection, radiosurgery, or a combination of these three interventions based on the lesion.
Collapse
|
|
20
|
Aoun SG, Bendok BR, Batjer HH. Acute Management of Ruptured Arteriovenous Malformations and Dural Arteriovenous Fistulas. Neurosurg Clin N Am 2012; 23:87-103. [PMID: 22107861 DOI: 10.1016/j.nec.2011.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Salah G Aoun
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine and McGaw Medical Center, 676 North Saint Clair Street, Chicago, IL 60611, USA
| | | | | |
Collapse
|
|
21
|
Salvati A, Ferrari C, Chiumarulo L, Medicamento N, Dicuonzo F, De Blasi R. Endovascular treatment of brain arteriovenous malformations ruptured during pregnancy--a report of two cases. J Neurol Sci 2011; 308:158-61. [PMID: 21719029 DOI: 10.1016/j.jns.2011.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 06/07/2011] [Indexed: 11/20/2022]
Abstract
Acutely ruptured brain arteriovenous malformations (AVMs) are a known etiology of hemorrhagic stroke during pregnancy. The aim of this paper is to report two cases of patients which presented with ruptured AVMs during pregnancy and were successfully treated with endovascular techniques. Peculiar issues related to the application of this treatment strategy in this category of patients will be discussed as well. To the best of our knowledge, this therapeutic approach in cerebral AVMs ruptured during pregnancy has not been described yet.
Collapse
Affiliation(s)
- Andrea Salvati
- Department of Neurological and Psychiatric Sciences, Neuroradiology Unit, University of Bari, Italy.
| | | | | | | | | | | |
Collapse
|
|
22
|
Laakso A, Dashti R, Juvela S, Isarakul P, Niemelä M, Hernesniemi J. Risk of hemorrhage in patients with untreated Spetzler-Martin grade IV and V arteriovenous malformations: a long-term follow-up study in 63 patients. Neurosurgery 2011; 68:372-7; discussion 378. [PMID: 21135742 DOI: 10.1227/neu.0b013e3181ffe931] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Treatment of Spetzler-Martin Grade IV and V brain arteriovenous malformations (ie, high-grade AVMs) carries a high risk of morbidity and even mortality. However, little is known about the behavior of these lesions if left untreated. OBJECTIVE To investigate the natural history of patients with high-grade AVMs. METHODS Patients with untreated high-grade AVMs admitted to our center between 1952 and 2005 were followed from admission until death, AVM rupture, or initiation of treatment. Rates of rupture and various risk factors were analyzed using Kaplan-Meier life table analyses and Cox proportional hazards models. Functional outcome was assessed 1 year after possible AVM rupture using the Glasgow Outcome Scale. RESULTS Sixty-three patients with a mean follow-up time of 11.0 years (range, 1 month to 39.6 years) were identified. Twenty-three patients (37%) experienced a subsequent rupture. The average annual rate of rupture was 3.3%. In patients with hemorrhagic presentation, the annual rate was 6.0%, compared to 1.1% in patients with unruptured AVMs (P = .001, log-rank test; hazard ratio, 5.09 [1.40-18.5, 95% CI]; P = .013, multivariate Cox regression model). One year after the first subsequent rupture, 6 patients (26%) had died, and 9 (39%) had moderate or severe disability. CONCLUSION Untreated high grade AVMs presenting with hemorrhage have a significant risk of subsequent rupture, and their rupture carries a higher risk of case fatality and permanent morbidity than AVMs in general. The risks associated with their treatment should be appraised in light of perilous natural history.
Collapse
Affiliation(s)
- Aki Laakso
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
| | | | | | | | | | | |
Collapse
|
|
23
|
Rahme R, Weil AG, Bojanowski MW. Outcome of severe arteriovenous malformation-related intracranial hemorrhage: the importance of cisternal subarachnoid hemorrhage and early seizures. Acta Neurochir (Wien) 2011; 153:897-903. [PMID: 21234617 DOI: 10.1007/s00701-010-0927-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 12/17/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although arteriovenous malformations (AVM)-related intracranial hemorrhage (ICH) is infrequently devastating, there is a subgroup of patients that present comatose requiring immediate surgical treatment. We sought to determine the outcome and prognostic factors in those patients with severe AVM-ICH. METHODS Between 2003 and 2009, medical records of 16 consecutive patients presented with severe AVM-ICH were retrospectively reviewed. Outcome was determined using 30-day survival and Glasgow outcome scale and modified Rankin scale scores at last follow-up. RESULTS There were seven males and nine females with a mean age of 32 years (range 6-66). All had Glasgow coma score 8 or less and most exhibited motor posturing and/or dilated pupils. Fifteen patients had intraprenchymal, ten had intraventricular, and four had subarachnoid hemorrhage (SAH). Twelve patients underwent hematoma evacuation with concomitant decompressive craniectomy in 11 and external ventricular drainage (EVD) in six. EVD was the only treatment offered to four patients. AVM excision was not routinely attempted in the acute phase. Three patients died from extensive bihemispheric infarction and refractory intracranial pressure. All 13 survivors improved neurologically and 12 had an acceptable functional outcome (modified Rankin scale ≤ 4) after a mean follow-up of 10 months (range 1-49). Among all clinical, radiological, and operative variables, only cisternal SAH (P = 0.007) and early seizures (P = 0.018) were significantly associated with death. CONCLUSION Despite their poor initial clinical condition, most survivors of severe AVM-ICH achieve an acceptable functional outcome. Therefore, patients with severe AVM-ICH, particularly those without aneurysmal-like SAH, should be managed aggressively given their remarkable potential for neurological recovery.
Collapse
|
|
24
|
Wong ST, Fong D. Ruptured brain arteriovenous malformations in children: correlation of clinical outcome with admission parameters. Pediatr Neurosurg 2010; 46:417-26. [PMID: 21540618 DOI: 10.1159/000324910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 02/02/2011] [Indexed: 11/19/2022]
Abstract
AIMS To gain a better understanding of how clinical outcome in children with ruptured brain arteriovenous malformations (bAVMs) correlates with clinical and imaging parameters on admission. METHODS The authors retrospectively reviewed patients with bAVMs, aged 18 or below, managed at their hospital between January 1992 and December 2008. Clinical outcome was assessed using the modified Rankin Scale (mRS). Patients with ruptured bAVMs were analyzed; their clinical parameters and computerized tomography findings on admission were recorded. Clinical outcome was then evaluated against admission scores using the Glasgow Coma Scale (GCS), the World Federation of Neurosurgical Societies Grading System of Subarachnoid Hemorrhage (WFNS-SAH), the Spetzler-Martin grade, the intracerebral hemorrhage score and 2 other independent parameters, namely pupillary response and significant focal neurological injuries. Spearman's correlation coefficient, linear regression analysis and multivariate logistic regression analysis were used for data analysis. RESULTS 40 pediatric patients with bAVMs were found and 32 of them presented with hemorrhage (80%). In the 32 children with ruptured bAVMS, follow-up ranged between 7 and 204 months (median 100.5 months). The complete excision/obliteration rate as confirmed by digital subtraction angiography was 73.3%. The mRS scores at the last follow-up were: grades 0-II in 87.5%; grades IV-V in 6.25%, and grade VI in 6.25%. The Spetzler-Martin grade, the intracerebral hemorrhage score, the WFNS-SAH grade, the GCS scores, and a combined scoring scale consisting of the GCS, pupillary response and significant focal neurological injuries correlated significantly with clinical outcome 6 months after hemorrhage. However, on the scatter diagrams, it appeared that only the combined scoring scale might be valid for clinical practice. Multivariate logistic regression analysis showed that the combined scoring scale was a statistically significant independent predictor of clinical outcome 6 months after hemorrhage. CONCLUSION In this series of pediatric patients with ruptured bAVMs, although various grading scales correlated significantly with clinical outcome 6 months after hemorrhage, only the combined scoring scale might have the potential to be applied to predict clinical outcome in these children.
Collapse
Affiliation(s)
- Sui-To Wong
- Department of Neurosurgery, Tuen Mun Hospital, Tuen Mun, Hong Kong, SAR, China.
| | | |
Collapse
|
|
25
|
Pavesi G, Rustemi O, Berlucchi S, Frigo AC, Gerunda V, Scienza R. Acute surgical removal of low-grade (Spetzler-Martin I-II) bleeding arteriovenous malformations. ACTA ACUST UNITED AC 2009; 72:662-7. [DOI: 10.1016/j.surneu.2009.03.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
|
|
26
|
Hernesniemi J, Romani R, Albayrak BS, Lehto H, Dashti R, Ramsey C, Karatas A, Cardia A, Navratil O, Piippo A, Fujiki M, Toninelli S, Niemelä M. Microsurgical management of pineal region lesions: personal experience with 119 patients. ACTA ACUST UNITED AC 2008; 70:576-83. [DOI: 10.1016/j.surneu.2008.07.019] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Accepted: 07/14/2008] [Indexed: 10/21/2022]
|
|
27
|
Nataf F, Schlienger M, Bayram M, Ghossoub M, George B, Roux FX. Microsurgery or Radiosurgery for Cerebral Arteriovenous Malformations? A Study of Two Paired Series. Neurosurgery 2007; 61:39-49; discussion 49-50. [PMID: 17621017 DOI: 10.1227/01.neu.0000279722.60155.d3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To detect parameters that may augment the therapeutic strategy in patients with a cerebral arteriovenous malformation (AVM) that is considered equally suitable for treatment by neurosurgery or radiosurgery, we compared the efficacy and risks of these two methods in a paired series with similar patient and AVM characteristics.
PATIENTS AND METHODS
Two series of patients with AVM were studied, including a series of 39 patients treated using microsurgery (MS) and another series of 39 patients treated via radiosurgery (RS). These series were paired for age and sex, initial symptoms, size, location and Spetzler-Martin grade, and presence of embolization preceding treatment. We compared the posttreatment outcome in the two groups with respect to obliteration rate, neurological status, mortality rate, and recurrent bleeding. Statistical analysis was performed using paired Student's t test.
RESULTS
The Glasgow Outcome Scale values and Modified Rankin Scores measured at discharge and 12 to 24 months were significantly better in the RS series than in the MS series. The obliteration rate tended to be higher in the MS series (91% versus 81%; P = 0.10, not significant), whereas the rate of neurological deficit was higher in the MS series than in the RS series(P < 0.001). The mortality rate was not significantly different in the two series, but the rate of recurrent bleeding was higher in the RS group (10% versus 0%; P = 0.04).
CONCLUSIONS
Although the rate of cure was similar for patients treated with MS and RS, neurological morbidity was higher after MS and recurrent bleeding was more frequent after RS.
Collapse
Affiliation(s)
- François Nataf
- Department of Neurosurgery, Sainte Anne Hospital, Paris, France.
| | | | | | | | | | | |
Collapse
|
|
28
|
Muñoz F, Clavel P, Molet J, de Teresa S, Solivera J, de Quintana C, Tresserras P, Rodríguez R, Bartumeus F, Castaño C. Manejo actual de las malformaciones arteriovenosas. Estudio retrospectivo de 31 casos y revisión de la literatura. Neurocirugia (Astur) 2007. [DOI: 10.1016/s1130-1473(07)70264-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
|
29
|
&NA;. Comments. Neurosurgery 2006. [DOI: 10.1227/00006123-200611001-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
|
30
|
Hernesniemi J, Niemelä M, Karatas A, Kivipelto L, Ishii K, Rinne J, Ronkainen A, Koivisto T, Kivisaari R, Shen H, Lehecka M, Frösen J, Piippo A, Jääskeläinen JE. Some collected principles of microneurosurgery: simple and fast, while preserving normal anatomy. ACTA ACUST UNITED AC 2005; 64:195-200. [PMID: 16099243 DOI: 10.1016/j.surneu.2005.04.031] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 04/02/2005] [Indexed: 11/19/2022]
Abstract
Microneurosurgical techniques introduced by Prof Yasargil in the 1960s have increased the neurosurgeon's ability to operate in small and often very narrow and deep gaps. Microneurosurgical techniques-ensuring an almost bloodless field and mostly obviating need for transfusion-should be atraumatic and noninvasive to the already lesioned central nervous system tissues and structures. Instruments in microneurosurgery range from very short to very long and from sturdy to delicate, depending on the working depth, characteristics of tissues, and the microneurosurgical anatomy. However, to keep it simple and fast, and to appreciate normal anatomy, it is preferable to use only a limited array of instruments. Besides the use of instruments and the operating microscope, everything else in the neurosurgical arena should be optimized and professional, such as the positioning of the patient and the conduct of neuroanesthesia. This review of the very basics is distilled from the Helsinki and Kuopio neurosurgery practices in Finland and from the senior author's (JH) experience of close to 10,000 operations, and this is to encourage young neurosurgeons of the world-most of them working with limited resources-to continue to improve their microneurosurgical skills to serve their patients best.
Collapse
Affiliation(s)
- Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Hospital, 00260 Helsinki, Finland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|