Name: comprehensive endovascular and open surgical management of cerebral arteriovenous malformations
Uploaded: 2017-10-20T12:30:00
Description: Watch this Scientific Journal Video about Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations at JoVE.com

The authors thank all the clinical teams contributing daily to the care of AVM patients at UCSD.

All procedures described below are performed as standard of care for patients with cerebral AVMs, after obtaining informed consent as per institutional guidelines.
1. Initial patient evaluation and imaging
NOTE: Patients with unruptured AVMs often present after the malformation is discovered on imaging for headache or seizure workup. Patients with ruptured AVMs often present with acute onset of headache, nausea, vomiting, weakness, numbness, and/or vision changes....

     

<ol>
	<li>Spetzler, R. F., Martin, N. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+proposed+grading+system+for+arteriovenous+malformations.">A proposed grading system for arteriovenous malformations.</a> J Neurosurg. 65 (4), 476-483 (1986).</li><li>Stapf, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Predictors+of+hemorrhage+in+patients+with+untreated+brain+arteriovenous+malformation.">Predictors of hemorrhage in patients with untreated brain arteriovenous malformation.</a> Neurology. 66 (9), 1350-1355 (2006).</li><li>Kondziolka, D., McLaughlin, M. R., Kestle, J. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simple+risk+predictions+for+arteriovenous+malformation+hemorrhage.">Simple risk predictions for arteriovenous malformation hemorrhage.</a> Neurosurgery. 37 (5), 851-855 (1995).</li><li>Fukuda, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multicenter+assessment+of+morbidity+associated+with+cerebral+arteriovenous+malformation+hemorrhages.">Multicenter assessment of morbidity associated with cerebral arteriovenous malformation hemorrhages.</a> J Neurointerv Surg. , (2016).</li><li>Conger, A., Kulwin, C., Lawton, M. T., Cohen-Gadol, A. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endovascular+and+microsurgical+treatment+of+cerebral+arteriovenous+malformations:+Current+recommendations.">Endovascular and microsurgical treatment of cerebral arteriovenous malformations: Current recommendations.</a> Surg Neurol Int. 6, (2015).</li><li>Mohr, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Medical+management+with+or+without+interventional+therapy+for+unruptured+brain+arteriovenous+malformations+(ARUBA):+a+multicentre,+non-blinded,+randomised+trial.">Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial.</a> Lancet. 383 (9917), 614-621 (2014).</li><li>Crawford, P. M., West, C. R., Chadwick, D. W., Shaw, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Arteriovenous+malformations+of+the+brain:+natural+history+in+unoperated+patients.">Arteriovenous malformations of the brain: natural history in unoperated patients.</a> J Neurol Neurosurg Psychiatry. 49 (1), 1-10 (1986).</li><li>Lawton, M. T., Kim, H., McCulloch, C. E., Mikhak, B., Young, W. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+supplementary+grading+scale+for+selecting+patients+with+brain+arteriovenous+malformations+for+surgery.">A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery.</a> Neurosurgery. 66 (4), 702-713 (2010).</li><li>Hemphill, J. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+Management+of+Spontaneous+Intracerebral+Hemorrhage:+A+Guideline+for+Healthcare+Professionals+From+the+American+Heart+Association/American+Stroke+Association.">Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.</a> Stroke. 46 (7), 2032-2060 (2015).</li><li>Gross, B. A., Frerichs, K. U., Du, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sensitivity+of+CT+angiography,+T2-weighted+MRI,+and+magnetic+resonance+angiography+in+detecting+cerebral+arteriovenous+malformations+and+associated+aneurysms.">Sensitivity of CT angiography, T2-weighted MRI, and magnetic resonance angiography in detecting cerebral arteriovenous malformations and associated aneurysms.</a> J Clin Neurosci. 19 (8), 1093-1095 (2012).</li><li>Hashimoto, T., Young, W. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anesthesia-related+considerations+for+cerebral+arteriovenous+malformations.">Anesthesia-related considerations for cerebral arteriovenous malformations.</a> Neurosurg Focus. 11 (5), 5 (2001).</li><li>Seldinger, S. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+replacement+of+the+needle+in+percutaneous+arteriography;+a+new+technique.">Catheter replacement of the needle in percutaneous arteriography; a new technique.</a> Acta. 39 (5), 368-376 (1953).</li><li>Abando, A., Hood, D., Weaver, F., Katz, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+use+of+the+Angioseal+device+for+femoral+artery+closure.">The use of the Angioseal device for femoral artery closure.</a> J Vasc Surg. 40 (2), 287-290 (2004).</li><li>Deshaies, E. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimodality+intraoperative+neurophysiological+monitoring+during+Onyx+embolization+of+cerebrovascular+malformations.">Multimodality intraoperative neurophysiological monitoring during Onyx embolization of cerebrovascular malformations.</a> Neurodiagn J. 55 (1), 12-24 (2015).</li><li>Vi&#241;uela, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Combined+endovascular+embolization+and+surgery+in+the+management+of+cerebral+arteriovenous+malformations:+experience+with+101+cases.">Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases.</a> J Neurosurg. 75 (6), 856-864 (1991).</li></ol>

Here we demonstrate a comprehensive approach to cerebral AVMs via combined endovascular and open surgical management. Catheter angiography is the gold standard for imaging AVMs, and is critical to surgical evaluation and planning. Pre-operative embolizations can simplify surgical resection, but requires communication between the surgical and interventional teams to develop an optimal strategic approach. For example, the AVM arterial feeders most easily embolized may also be the most surgically accessible. If, however, th...

Cerebral arteriovenous malformations (AVMs), abnormal connections between arteries and veins without intervening normal capillary beds, present unique neurosurgical challenges. Classified based on size, presence of deep draining veins, and involvement of eloquent cortex,1 the risk of hemorrhage for previously unruptured AVMs ranges from 0.9 to 8% per year,2 with an annual average rupture risk of ~3%.3 Hemorrhages from AVMs are associated with a nearly 10% mortality rate and significant morbidity, with up to 34% of patients having moderate to severe disabilities.4 Previously ruptured AVMs have increased annual hemorrhage rates,2 but a relatively low immediate risk of re-rupture. Unless mass effect from a hematoma demands acute intervention, treatment is often performed on an elective basis after weighing the expected natural history of a lesion versus its treatment-associated risks.5,6
Surgical resection is the treatment of choice for small accessible AVMs as it immediately and definitively eliminates future hemorrhage risk. However, the high flow rate of AVMs, as well as the increased risk of AVM-associated aneurysms,4,7 makes surgical resection amongst the most challenging of all neurosurgical cases. Pre-operative embolization of AVMs to reduce blood flow and remove high-risk AVM features can significantly reduce the technical challenges of resection.
Comprehensively trained vascular neurosurgeons are uniquely positioned to definitively treat AVMs by performing both the pre-operative angiogram and endovascular embolization, as well as the open surgical resection. Herein, we describe the protocol for management of surgically accessible cerebral AVMs (as defined by established grading scales1,8 as well as surgeon and multidisciplinary conference evaluations) at our institution.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>ChloraPrep Sterilization Solution</td>
			<td>BD, Franklin Lakes, NJ</td>
			<td>260815</td>
			<td>For skin sterilization</td>
		</tr>
		<tr>
			<td>Lidocaine Hcl 1%&#160;</td>
			<td>ACE Surgical Supply, Inc, Brockton, MA</td>
			<td>001-1421</td>
			<td>For local anesthetic</td>
		</tr>
		<tr>
			<td>Micropuncture Groin Access Kit</td>
			<td>Cook Medical, Bloomington, IN</td>
			<td>G56202</td>
			<td>Used for femoral artery access</td>
		</tr>
		<tr>
			<td>0.035 Guidewire&#160;</td>
			<td>Terumo Medical, Somerset, NJ</td>
			<td>GR3506</td>
			<td>Used in conjunction with diagnostic catheters for cerebral angiography</td>
		</tr>
		<tr>
			<td>Cerebral Angiography Diagnostic Catheters&#160;</td>
			<td>Terumo Medical, Somerset, NJ</td>
			<td>CG416</td>
			<td>Used in conjunction with guidewire for cerebral angiography</td>
		</tr>
		<tr>
			<td>Omnipaque Contrast Agent</td>
			<td>GE Healthcare, Chicago, IL&#160;</td>
			<td>Q9965</td>
			<td>Contrast agent for cerebral vessel imaging</td>
		</tr>
		<tr>
			<td>Microcatheter and Microwire</td>
			<td>Covidian, Plymouth, MN</td>
			<td>105-5091-150, 103-0608</td>
			<td>Used for distal arterial catheterization</td>
		</tr>
		<tr>
			<td>Onyx Liquid Embolic</td>
			<td>Covidian, Plymouth, MN</td>
			<td>105-7100-060</td>
			<td>Used for AVM embolization</td>
		</tr>
		<tr>
			<td>Angio-Seal Vascular Closure Device</td>
			<td>St. Jude Medical, St Paul, MN</td>
			<td>610130</td>
			<td>Used for femoral artery closure following angiography/intra-arterial embolization</td>
		</tr>
		<tr>
			<td>Midas Rex High Power Drill System</td>
			<td>Medtronic, Minneapolis, MN</td>
			<td>PM700</td>
			<td>Used for craniotomy&#160;</td>
		</tr>
		<tr>
			<td>Matchstick Drill Bit</td>
			<td>Medtronic, Minneapolis, MN</td>
			<td>10MH30-MN</td>
			<td>Used to create burr hole for craniotomy&#160;</td>
		</tr>
		<tr>
			<td>Tapered Drill Bit</td>
			<td>Medtronic, Minneapolis, MN</td>
			<td>F1/8TA15</td>
			<td>Used to complete craniotomy&#160;</td>
		</tr>
		<tr>
			<td>#11 and 15 Blade Surgical Scalpels</td>
			<td>BD Bard-Parker, Franklin Lakes, NJ</td>
			<td>372615&#160;</td>
			<td>Used for groin incision for angiography and dural opening for external ventricular drain placement or AVM resection</td>
		</tr>
		<tr>
			<td>Metzenbaum Dissecting Scissors</td>
			<td>Stoelting Co, Wood Dale, IL</td>
			<td>52134-01P</td>
			<td>Used for dural opening</td>
		</tr>
		<tr>
			<td>Bone Elevator</td>
			<td>Stoelting Co, Wood Dale, IL</td>
			<td>52169</td>
			<td>Used for separating dura from the inner skull</td>
		</tr>
		<tr>
			<td>Gerald Forceps</td>
			<td>Stoelting Co, Wood Dale, IL</td>
			<td>52106-52</td>
			<td>Used for dural opening and manipulation</td>
		</tr>
		<tr>
			<td>Microsurgical Instruments&#160;</td>
			<td>Accurate Surgical &#38; Scientific Instruments Corporation, Westbury, NY</td>
			<td>ASSI.BML1</td>
			<td>Used for AVM microsurgical resection</td>
		</tr>
		<tr>
			<td>Bipolar Forceps&#160;</td>
			<td>Accurate Surgical &#38; Scientific Instruments Corporation, Westbury, NY</td>
			<td>ASSI.BPNS20423FP</td>
			<td>Used for AVM microsurgical resection</td>
		</tr>
		<tr>
			<td>Electrosurgery Generator</td>
			<td>Bovie Medical Products, Clearwater, FL&#160;</td>
			<td>IDS-200&#160;</td>
			<td>Used for electrosurgical cutting/coagulation</td>
		</tr>
		<tr>
			<td>Small Aneurysm Clips</td>
			<td>Codman Neuro, Raynham, MA</td>
			<td>20-1801</td>
			<td>Used for occlusion of arterial AVM feeders not amenable to coagulation</td>
		</tr>
		<tr>
			<td>Brain Retractors</td>
			<td>Medicon, Tuttlingen, Germany</td>
			<td>22.00.06</td>
			<td>For brain retraction for deep AVM dissection/resection</td>
		</tr>
		<tr>
			<td>Variable Action Suction tip</td>
			<td>Millennium Surgical, Narberth, PA</td>
			<td>6-8607</td>
			<td>For suction with AVM dissection/resection</td>
		</tr>
		<tr>
			<td>Fibrillar Absorbable Hemostatic Agent</td>
			<td>Ethicon, Somerville, NJ</td>
			<td>63713-0019-61</td>
			<td>For hemostatis within surgical cavity</td>
		</tr>
		<tr>
			<td>4-0 Suture</td>
			<td>Ethicon, Somerville, NJ</td>
			<td>C554D</td>
			<td>For dural closure</td>
		</tr>
		<tr>
			<td>2-0 Absorbable Suture</td>
			<td>Ethicon, Somerville, NJ</td>
			<td>J286G</td>
			<td>For deep tissue closure</td>
		</tr>
		<tr>
			<td>3-0 Nylon Suture</td>
			<td>Ethicon, Somerville, NJ</td>
			<td>ET-663G</td>
			<td>For skin closure</td>
		</tr>
		<tr>
			<td>Surgical Staples&#160;</td>
			<td>Medline, Mundelein, IL</td>
			<td>STAPLER35RB</td>
			<td>For skin closure</td>
		</tr>
		<tr>
			<td>Bone Plating System</td>
			<td>Biomet, Warsaw, IN</td>
			<td>15-7378-12</td>
			<td>For bone flap securement</td>
		</tr>
		<tr>
			<td>Operating Microscope</td>
			<td>Leica Microsystems, Buffalo Grove, IL</td>
			<td>M720 OH5</td>
			<td>Used for AVM microsurgical resection</td>
		</tr>
		<tr>
			<td>BrainLab Neuronavigation Imaging System</td>
			<td>Brainlab, Inc, Chicago, IL</td>
			<td>Brainlab Curve&#160;</td>
			<td>Used for AVM microsurgical resection</td>
		</tr>
		<tr>
			<td>Lumbar External Drainage System</td>
			<td>Codman Neuro, Raynham, MA</td>
			<td>K964923</td>
			<td>Used for placement of lumbar drain for CSF drainage</td>
		</tr>
		<tr>
			<td>External Ventricular Drainage Catheter</td>
			<td>Medtronic, Minneapolis, MN</td>
			<td></td>
			<td>Used for placement of ventricular catheter for CSF drainage</td>
		</tr>
		<tr>
			<td>Disposable Raney Scalp Clips</td>
			<td>A&#38;E Medical Corporation, Farmingdale, NJ</td>
			<td>070-001</td>
			<td>Used for scalp hemostasis</td>
		</tr>
	</tbody>
</table>

comprehensive endovascular and open surgical management of cerebral arteriovenous malformations

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs must be tailored specifically to the lesion, with surgical resection being the gold standard for small, accessible lesions. Pre-operative embolization of AVMs can reduce nidal blood flow and remove high-risk AVM features such as intranidal or venous aneurysms, thereby simplifying a challenging neurosurgical procedure. Herein, we describe our approach for the staged endovascular embolization and open resection of AVMs, and highlight the advantages of having a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team. This includes planning the craniotomy and resection to immediately follow the final embolization stage, thereby using a single session of anesthesia for aggressive embolization, and rapid resection. Finally, we provide a representative case of a 22-year-old female with an unruptured right frontal AVM diagnosed during a seizure workup, who was successfully treated via staged embolizations followed by open surgical resection.

A 22-year-old previously healthy female presented with new onset seizures. Non-contrast head CT was negative for acute hemorrhage, but revealed an incompletely characterized right frontal lesion. MRI demonstrated an approximately 2.9 x 2.4 cm Spetzler-Martin Grade 3 AVM within the right superior frontal gyrus (Figure 1), with large draining cortical veins going to the superior sagittal sinus, and an arterial supply via large branches off the right middle cerebral artery. ...

Watch this Scientific Journal Video about Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations at JoVE.com

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Surgery is the gold standard for accessible arteriovenious malformations (AVMs), and pre-operative embolization can simplify this procedure. We describe our approach for staged endovascular embolization and open resection of AVMs, and provide a representative clinical example highlighting the advantages of a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team.

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

The overall goal of this combined intervention is to safely treat intracranial arteriovenous malformations. This is accomplished via preoperative embolization to first reduce blood flow and remove high-risk arteriovenous malformation features. This is followed by surgical resection with the preceding embolization potentially significantly reducing the technical challenges of the surgery.The goal of this protocol is to allow for the safe and comprehensive treatment of intracranial arteriovenous malformations. Using a combination of endovascular techniques and open surgery, we begin to develop a greater understanding of these intricate and complex lesions. With each progressive arterial embolization, we develop a higher risk of a loss of venous outflow and hemorrhage.We therefore are in a position with our final embolization, under a single setting of anesthesia, to take the patient after that embolization immediately to surgery for a complete resection. Our case is a 22-year-old gentleman who presented with an intracranial hemorrhage from a ruptured AVM. This Spetzler-Martin grade III AVM left him with a visual field cut on the left side.He presents for treatment today after a series of staged embolizations by my interventional partner. We're going to perform a final stage of embolization with the goal to reduce the AVM to one arterial distribution and then proceed with definitive surgical resection. His indication for the procedure are his young age, the Spetzler-Martin grade, and his personal history of rupture.Position the patient supine on the fluoroscopy table after administration of general anesthesia with assistance from the anesthesiology team. Prepare the patient for embolization surgery with the neuromonitoring team. Establish baseline and continuous neuromonitoring signals via somatosensory evoked potentials, transcranial motor evoked potentials, auditory brainstem responses, and/or electroencephalography.After preparing the patient for surgery, begin by placing the right femoral artery sheath. Prepare to use a modified Seldinger technique with a micropuncture groin access kit. To begin, clean the groin with alternating solution scrubs, and drape the surrounding area.Next, inject one to two milliliters of 1%lidocaine subcutaneously. Then, palpate the femoral artery at the inguinal crease. After applying the local anesthetic, insert the microneedle into the femoral artery lumen at a 45 degree angle.Next, insert the microwire, and advance it into the artery lumen. Then remove the microneedle, make a small skin incision, and insert a vessel dilator over the microwire. Then remove the microwire and inner portion of the vessel dilator, and insert a J-wire into the artery.Remove the vessel dilator, keeping the J-wire in place. Now, introduce a size five or six French sheath over the J-wire and into the vessel lumen. Once in place, remove the J-wire.Next, set up a mono-or biplane fluoroscope updating at three to five frames per second. To proceed with the AVM embolization, introduce a preassembled coaxial system into the femoral sheath. Now, under fluoroscopy, advance the coaxial system cephalad into the ascending aorta.Along the way, inject small boluses of radiopaque contrast agent for visualization. In the ascending aorta, selectively catheterize the large caliber vessel from which the desired feeding AVM vessel originates with a diagnostic catheter, and advance the guide catheter to the appropriate cervical segment for support. Then, remove the diagnostic catheter and guide wire, and perform a diagnostic angiogram by injecting a radiopaque contrast agent.Overlay guidance or roadmap images are then created to assist with microcatheterization of the target AVM vessel. Next, introduce a microcatheter and microwire into the guide catheter, and selectively catheterize the desired feeding artery under overlay or roadmap guidance. Embolize the nidus and desired feeding artery, using a controlled injection of radiopaque contrast agent.In the highlighted case, a pedicle off the right fetal variant posterior cerebral artery was selected as the first target for embolization. The volume of solution needed depends on the size of the lesion. Be careful during this process, as there is a risk of embolizate reflux into non-AVM arteries or distal embolization into draining veins.Repeat a guide catheter run to evaluate the embolization and patency of the parent vessels. Perform repeat microcatherizations and embolizations of all desired AVM pedicles, prioritizing arterial feeders that are the least surgically accessible. As the risk of venous outflow obstruction and rupture increases with progressive AVM embolizations, a final aggressive embolization should only be performed when a craniotomy and resection is planned to immediately follow.In the highlighted case, two posterior cerebral artery pedicles and three middle cerebral artery pedicles in total were embolized prior to immediate transfer to the operating room for resection of the AVM. Perform a final diagnostic angiogram of involved vessels to evaluate overall AVM embolization and ensure patency of parent vessels. Finally, withdraw the coaxial system and sheath, and secure the femoral artery with a sealant device.If the patient is being taken directly to the OR for resection, the femoral sheath may be left in place or exchanged for a flexible sheath for intraoperative angiogram. This procedure begins by performing a wide craniotomy at the AVM location. Ideally, the craniotomy site will be chosen to allow early access to cerebrospinal fluid cisterns for drainage if needed.The patient is positioned to ensure adequate cerebral venous drainage. Neuromonitoring signals are established or continued if already established during embolization. Neuronavigation is synced with preoperative imaging and registered.A planned incision is marked, the surgical site is prepped, local anesthetic is administered, and the field is draped. First, incise the skin and galea, using a number 15 blade. Then, obtain hemostasis, using electrocautery and Raney clips.Elevate a soft tissue flap, using a combination of electrocautery and blunt dissection to the level of the cranium or pericranium. If desired, a pericranial flap can be harvested at this point and used later for closure. Hooks are used for soft tissue retraction to maximize surgical exposure.Now, create one or multiple burr holes on the periphery of the desired craniotomy with a perforator drill bit attached to a high-powered drill. Around the burr hole, strip the dura from the inside of the skull using a bone elevator or footplate attachment. If the craniotomy is over a venous sinus, burr holes are planned to allow complete stripping of underlying dura at the sites where the craniotomy crosses the sinus.Then, complete the craniotomy by connecting the burr holes. Use a tapered drill bit and, for dural protection, a footplate attachment on the high-speed drill. Great care is taken when cutting over a venous sinus.Remove the bone after detaching it from the underlying dura. Irrigate and obtain hemostasis, using bipolar electrocautery. Next, place dural tack-up sutures to close off the epidural space by drilling small holes in the bone around the craniotomy with a C1 drill bit and securing the dura to the bone at these sites using 4-0 sutures.Then, open the dura sharply and carefully, using a number 11 blade. Do not injure the underlying cortex or vessels. Then, open the remaining exposed dura in either a cruciate or C-shaped fashion, using Metzenbaum scissors and Gerald forceps.Use the forceps to elevate the dural edge and visualize the tips of the scissors while cutting. Obtain hemostasis after dural opening, using irrigation and bipolar electrocautery. While not the case in this procedure, in the setting of an acute rupture and emergent surgery, it's important to actually decompress the clot only sufficiently to allow for brain relaxation and microdissection of the arterial feeders.Complete resection of the clot should be reserved after all potentially angiographically occult components of the AVM have been identified at the time of surgery. Now, under an operating microscope or exoscope, excise the AVM. Start by first dissecting within the subarachnoid space, using a combination of blunt and sharp technique to define the AVM anatomy by exposing its margins and free draining veins.Also obtain proximal control by identifying and dissecting free all of the feeding arteries. Take great care to identify and preserve the draining veins, as occlusion of the venous drainage prior to the arterial feeders results in engorgement of the AVM and increases rupture risk. After defining the anatomy, coagulate the arterial feeding arteries as they enter the AVM in a proximal to distal fashion, using bipolar electrocautery.Gently hold the vessel between the tips of the bipolar forceps, and run up to 30 watts of current. Dissect circumferentially within the brain parenchyma immediately around the AVM nidus, using bipolar forceps and a variable action suction tip. A brain retractor may be used to facilitate visualization for deep dissections.After completing the dissection, coagulate or clip draining vessels as needed. Then, remove the AVM from the resection cavity. Obtain meticulous hemostasis, using bipolar electrocautery as before and by gently lining the resection cavity with absorbable hemostatic agents.After removing the AVM, perform an intraoperative angiogram, using the previously placed arterial sheath and intraoperative single or biplane angiography or C-arm fluoroscopy. Intraoperative angiogram of the right internal carotid and vertebral artery in the highlighted case demonstrated a complete AVM resection. Following a satisfactory resection, close or reapproximate the dura using 4-0 sutures and, if needed, a dural graft.Replace and secure the bone flap, using a plating system, and close the galea and skin, using interrupted absorbable sutures for the deep layers and either staples or running suture for the skin. Finally, remove the groin sheath, and secure the groin. Extubate the patient if able, and transfer to the ICU for neurologic monitoring and recovery.After this dual procedure, the patient was discharged after a short hospital stay at his neurologic baseline. To reiterate the applications of this technique, another case where combined endovascular and open surgical approach was used for AVM resection is reviewed. A 22-year-old, previously health female presented with new onset seizures.Non-contrast head CT was negative for acute hemorrhage but revealed an incompletely characterized right front lesion. MRI demonstrated an approximately 2.9 by 2.4 centimeter Spetzler-Martin grade III AVM within the right superior frontal gyrus with large draining cortical veins going to the superior sagittal sinus and an arterial supply via large branches off the right middle cerebral artery. The patient underwent multiple staged endovascular embolizations, culminating in an embolization of a right anterior cerebral artery pedicle.At the completion of these staged embolizations, there was residual supply to the nidus via the distal right middle and anterior cerebral artery branches and an indirect supply from the left external carotid artery via the distal superior temporal artery branches that anastomosed to the middle meningeal artery via transosseous collaterals. The patient then underwent a frontotemporal craniotomy, wherein the medial draining veins were identified early and protected. All arterial feeders were also identified, bipolared, and cut to achieve sequential devascularization prior to removal of the AVM nidus.Intraoperative and postoperative catheter angiogram confirmed complete resection. One month postoperatively, the patient was neurologically stable and being weaned from antiseizure medications, with plans for delayed cerebral vascular imaging at one year. Our case today and the featured case in our figure example demonstrate the value of a combined endovascular and surgical approach for these complex lesions.We've demonstrated the value of developing an intricate understanding of the pathophysiology and anatomy and protecting the patient from risks of rupture, progressive occlusion, or stroke. No less important are the neuroanesthesiologist, neuromonitoring, and neurointensive care professionals that carry the patient through their operative journey. For these reasons, we believe this technique should be best applied in high-volume experience centers.

Research

JoVE Journal

Neuroscience

Focal Cerebral Ischemia Model by Endovascular Suture Occlusion of the Middle Cerebral Artery in the Rat

Stroke is the leading cause of disability and the third leading cause of death in adults worldwide1. In human stroke, there exists a highly variable ...

Dual Electrophysiological Recordings of Synaptically-evoked Astroglial and Neuronal Responses in Acute Hippocampal Slices

Astrocytes form together with neurons tripartite synapses, where they integrate and modulate neuronal activity. Indeed, astrocytes sense neuronal inputs ...

Isolation and Cannulation of Cerebral Parenchymal Arterioles

Intracerebral parenchymal arterioles (PAs), which include parenchymal arterioles, penetrating arterioles and pre-capillary arterioles, are high resistance ...

Optimized Management of Endovascular Treatment for Acute Ischemic Stroke

This manuscript describes a streamlined protocol for the management of patients with acute ischemic stroke, which aims at the minimization of time from ...

A Rat Model of Mild Intrauterine Hypoperfusion with Microcoil Stenosis

Intrauterine hypoperfusion/ischemia is one of the major causes of intrauterine/fetal growth restriction, preterm birth, and low birth weight. Most studies ...

Comprehensive Autopsy Program for Individuals with Multiple Sclerosis

We describe a rapid tissue donation program for individuals with multiple sclerosis (MS) that requires scientists and technicians to be on-call 24/7, 365 ...

Simulator Training for Endovascular Neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging (MRI)

Endovascular Perforation Model for Subarachnoid Hemorrhage Combined with Magnetic Resonance Imaging MRI

The endovascular filament perforation model to mimic subarachnoid hemorrhage (SAH) is a commonly used model - however, the technique can cause a high ...

Mapping Cerebral Blood Flow and Electrical Fields: Electrode Placement in Mice

Placement of Extracranial Stimulating Electrodes and Measurement of Cerebral Blood Flow and Intracranial Electrical Fields in Anesthetized Mice

Stimulation-Based Approach to Improve Cerebral Blood Flow in Alzheimer's Model (Video) | JoVE

The detection of cerebral blood flow (CBF) responses to various forms of neuronal activation is critical for understanding dynamic brain function and ...

Unveiling Mitochondrial Ultrastructure in Neurons Using STED Microscopy

Using Live Cell STED Imaging to Visualize Mitochondrial Inner Membrane Ultrastructure in Neuronal Cell Models

Decoding Mitochondrial Aging (Video) | JoVE

Mitochondria play many essential roles in the cell, including energy production, regulation of Ca2+ homeostasis, lipid biosynthesis, and production of ...