title: Management of residual dysplastic vessels after cerebral arteriovenous malformation resection: implications for postoperative angiography.
abstract: OBJECTIVE
  The verification of surgical resection of cerebral arteriovenous malformations (AVMs) relies on angiography. Abnormal vasculature often is identified after removal of the AVM. Differentiation of dysplastic feeding vessels that resemble the neovascularity of moyamoya disease, as distinct from residual AVM, is crucial for preserving critical brain areas. We review a large experience with immediate postoperative angiography after AVM resection and discuss the implications for management of abnormal dysplastic vessels discovered after AVM resection.
  
  
  METHODS
  Beginning in 1992, 86 consecutive patients with AVMs underwent operations by standard protocol for immediate postoperative angiography under the same general anesthetic. Angiographic interpretation dictated admission to the intensive care unit or return to the operating room for further resection.
  
  
  RESULTS
  In 78 patients, the angiogram revealed complete resection. Two patients were returned to the operating room, one for residual malformation with an early draining vein, and one for resection of residual dysplastic vessels. There was one postoperative hemorrhage in a patient whose postoperative angiogram was falsely negative for AVM. Six patients with residual dysplastic vessels mimicking residual AVM, but without an early draining vein, were managed conservatively. Delayed follow-up angiography demonstrated spontaneous involution of these abnormal vessels in all of these patients.
  
  
  CONCLUSIONS
  Residual dysplastic feeding vessels resembling the neovascularity of moyamoya disease but not associated with an early draining vein do not necessarily represent residual malformation after AVM resection. The abnormal vessels will proceed to complete spontaneous resolution. Given the difficulty of interpreting intraoperative angiography, immediate postoperative angiography may be a viable alternative after AVM resection.
authors.affiliation: Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York 10032, USA. ras5@columbia.edu
authors.forename: R A
authors.initials: RA
authors.lastname: Solomon
authors.forename: E S
authors.initials: ES
authors.lastname: Connolly
authors.forename: C J
authors.initials: CJ
authors.lastname: Prestigiacomo
authors.forename: A G
authors.initials: AG
authors.lastname: Khandji
authors.forename: J
authors.initials: J
authors.lastname: Pile-Spellman
mesh_terms: D000328:Adult; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging / Q000601:surgery*; D009072:Moyamoya Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000601:surgery*; D011237:Predictive Value of Tests; D012086:Reoperation