Emergency craniotomy for intraparenchymal massive hematoma after embolization of supratentorial arteriovenous malformations.
OBJECTIVE
We sought to evaluate the efficacy of emergency craniotomy for patients with massive hematoma secondary to endovascular embolization of supratentorial arteriovenous malformations (AVMs) and to investigate relevant factors affecting outcome.


METHODS
Within the past 15 years, 605 patients with intracranial AVMs have undergone 1066 endovascular embolizations at our institution. Of these, 24 patients experienced intracranial hemorrhage during or after the procedure. Fourteen patients were demonstrated to have massive intraparenchymal hematomas and deteriorated to a comatose state (Glasgow Come Scale score < or =6). Twelve patients underwent craniotomy within 170 minutes of being diagnosed with intraparenchymal hemorrhage. The surgical procedures performed were hematoma evacuation with total (6 patients) or partial (2 patients) resection of the AVM or hematoma evacuation only (4 patients). The clinical records of these 12 patients were analyzed retrospectively.


RESULTS
Nine patients recovered to a favorable condition (good recovery, four patients; moderately disabled, five patients), one patient remained in a persistent vegetative state, and two patients died. The interval between hemorrhage and emergency craniotomy was significantly shorter in patients with favorable outcomes than in those with poor clinical outcomes. Advanced age and a larger volume of intraoperative blood loss were the factors relevant to poor outcome. Temporal lobe location of the AVM and incomplete embolization tended to correlate to poor clinical outcome, but this correlation was not statistically significant. The sizes of the AVM and the hematoma did not correlate to patient outcome. There was no difference in outcomes with regard to the surgical procedure performed.


CONCLUSIONS
In patients with massive postembolization hematomas, emergency craniotomy should be performed as soon as possible to achieve a favorable outcome. Cooperation among interventional neuroradiologists, intensive care physicians, and neurosurgeons is essential to manage AVM patients with critical postembolization hemorrhage. There is no need to persist in performing simultaneous total resection of the AVM at the emergency craniotomy.
Iwama
Toru
T
Department of Neurosurgery and Institute of Neuroradiology, University Hospital Zürich, Zürich, Switzerland.
Yoshimura
Kunikazu
K
Keller
Emanuela
E
Imhof
Hans-Georg
HG
Khan
Nadia
N
Leblebicioglu-Könu
Dilek
D
Tanaka
Michihiro
M
Valavanis
Anton
A
Yonekawa
Yasuhiro
Y
D000328:Adult; D002543:Cerebral Hemorrhage / Q000209:etiology / Q000601:surgery*; D003399:Craniotomy; D003422:Critical Care; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D004630:Emergencies; D005260:Female; D023261:Glasgow Outcome Scale; D006406:Hematoma / Q000209:etiology / Q000601:surgery*; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome