Abstract
We have surgically treated 36 patients with cerebral arteriovenous malformations (AVMs) since 1991, when intraoperative digital subtraction angiography (DSA) was introduced. The patients ranged in age from 6 to 67 years (mean=33.8) and had a mean grade of 3.4. Preoperative embolization was employed in 18 patients to occlude surgically inaccessible feeders and to reduce arterial blood supply to large AVMs by 50%. The embolic material was silk thread and polyvinyl alcohol particles in 9 patients, and liquid coils in 9. Intraoperative DSA using portable equipment was used in all 36 patients. Frameless stereotactic microsurgery with the Mehrkoordinaten Manipulator (MKM) system was performed in 4 patients; 2 patients had trigone AVM, one motor cortex AVM, and the other sylvian AVM. Endovascular embolization resulted in transient hemianopsia in 1 patient but no permanent deficits nor death. Three patients underwent partial resection, after which the residual nidus involving the motor cortex, the thalamus, and the basal ganglion was stereotactically irradiated. One patient died of postoperative bleeding complication, and mild neurological deficits appeared in 2 patients. Surgical mortality and morbidity were 2.8% and 5.6%. In conclusion, endovascular feeder occlusion is safe and useful as a preoperative adjuvant therapy. Intraoperative DSA is essential for the surgery of cerebral AVMs, and image-guided microsurgery allows stereotactic access to deep-seated lesions while sparing the brain.
