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 ...

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