title: Safe resection of arteriovenous malformations in eloquent motor areas aided by functional imaging and intraoperative monitoring.
abstract: BACKGROUND
  Arteriovenous malformations (AVMs) proximal to motor cortical areas or motor projection systems are challenging to manage because of the risk of severe sensory and motor impairment. Surgical indication in these cases therefore remains controversial.
  
  
  OBJECTIVE
  To propose a standardized approach for centrally situated AVMs based on functional imaging and intraoperative electrophysiological evaluation.
  
  
  METHODS
  We conducted a retrospective analysis of 15 patients who underwent surgical treatment for AVMs in motor cortical areas or proximal to motor projections. Preoperative assessment included functional magnetic resonance and 3-dimensional tractography. Operations were performed under continuous electrophysiological monitoring aided by direct brain stimulation. We identified critical bloody supply to the motor areas by temporary occluding the feeding vessels under electrophysiological monitoring. Clinical outcome was evaluated with the modified Rankin Scale.
  
  
  RESULTS
  Total resection was achieved in 12 cases, whereas electrophysiology limited total extirpation in 3 cases. A significant reduction of motor evoked potentials by up to 15% of the initial values was associated with good recovery of motor function; in contrast, the disappearance of potentials correlated with long-term impairment. The mean follow-up time was 13 months, and clinical assessments revealed overall functional improvement (P < .05). After surgery, 11 patients were asymptomatic or presented with only minor neurological deficits.
  
  
  CONCLUSIONS
  Surgical resection of AVMs in eloquent motor areas can be considered a safe option for selected cases when performed in conjunction with a detailed functional assessment. Possible selection criteria for surgical treatment are discussed in light of the presented clinical data.
authors.affiliation: Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Baden-Württemberg, Germany. lepski@gmail.com
authors.forename: Guilherme
authors.initials: G
authors.lastname: Lepski
authors.forename: Jürgen
authors.initials: J
authors.lastname: Honegger
authors.forename: Marina
authors.initials: M
authors.lastname: Liebsch
authors.forename: Marília Grando
authors.initials: MG
authors.lastname: Sória
authors.forename: Porn
authors.initials: P
authors.lastname: Narischat
authors.forename: Kristofer Fingerle
authors.initials: KF
authors.lastname: Ramina
authors.forename: Thomas
authors.initials: T
authors.lastname: Nägele
authors.forename: Ulrike
authors.initials: U
authors.lastname: Ernemann
authors.forename: Marcos
authors.initials: M
authors.lastname: Tatagiba
mesh_terms: D000328:Adult; D001165:Arteriovenous Malformations / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery*; D002533:Cerebral Angiography / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods*; D009044:Motor Cortex / Q000098:blood supply / Q000601:surgery*; D038361:Neuronavigation / Q000379:methods*; D011300:Preoperative Care / Q000379:methods*; D012189:Retrospective Studies; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods