Present state of microneurosurgery of cerebral arteriovenous malformations.
Microneurosurgical excision is known to be the definitive treatment for brain arteriovenous malformation (AVMs). The most important factors governing the operability of an AVM are location, size, age of the patient, and the neurosurgeon's and team's experience. We present in this review the surgical experience of the senior author (JH) in microneurosurgical treatment of brain AVMs. This consists of the following steps: (1) accurate preoperative embolization; (2) optimal selection of the surgical approach; (3) accurate definition and preservation of the normal arterial vessels of passage; (4) temporary clipping of the feeding arteries; (5) a special method of coagulation called "dirty coagulation" of the deep small difficult vessels inside apparently normal brain around the AVM; (6) removal of all AVM; (7) meticulous hemostasis; (8) intra- and postoperative digital subtraction angiography (DSA); (9) clinical and radiological follow-up. These steps are not possible in AVMs lying entirely within central eloquent areas. Nine out of ten small- and medium-sized arteriovenous malformations (AVMs) are suitable for direct surgery, but surgical complications increase drastically with the size of the AVM. Nevertheless, the actual results of combined treatment with preoperative Onyx embolization followed by microsurgery have decreased these risks.
Hernesniemi
Juha
J
Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland. juha.hernesniemi@hus.fi
Romani
Rossana
R
Lehecka
Martin
M
Isarakul
Puchong
P
Dashti
Reza
R
Celik
Ozgür
O
Navratil
Ondrej
O
Niemelä
Mika
M
Laakso
Aki
A
D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000175:diagnosis / Q000601:surgery*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008866:Microsurgery / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome