Combined Endovascular and Microsurgical Treatment of Arteriovenous Malformations in the Hybrid Operating Room

• Published in: World neurosurgery 2018-09, Vol.117, p.e204-e214
• Main Authors: Grüter, Basil E., Mendelowitsch, Itai, Diepers, Michael, Remonda, Luca, Fandino, Javier, Marbacher, Serge
• Format: Article
• Language: English
• Subjects: Cerebral arteriovenous malformation; Endovascular treatment; Hybrid operating room; Intraoperative angiography; Microsurgical treatment
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2018.05.241

Radical treatment of brain arteriovenous malformations (AVMs) remains a challenge despite recent advances in endovascular, microsurgical, and stereotactic radiosurgery treatments. The radical removal of AVMs with prevention of hemorrhage can be achieved through either single or combined modalities. Our retrospective study summarizes the safety and efficacy of combined endovascular embolization and microsurgical removal of AVMs in 49 consecutive patients in the hybrid operating room (hOR). Patients underwent nonhybrid (i.e., endovascular, stereotactic radiosurgery, observation, combination) or hybrid (i.e., endovascular with microsurgery in hOR) treatment. The variables analyzed included age, sex, hospitalization time, Spetzler-Martin/Buffalo grades, clinical symptoms, previous treatment, intraoperative digital angiographic (iDSA) findings, postsurgical treatment, operation duration, complications, obliteration rate, and remnants. Of 18 patients treated in the hOR, 15 (83%) presented with Spetzler-Martin grades I and II and were younger than those treated with other modalities (mean age, 41 vs. 46 years). Thirteen (87%) patients were admitted with signs of hemorrhage after AVM rupture. The initial surgical plan was modified in 3 (17%) of 18 cases based on iDSA findings. All patients who eventually underwent microsurgical removal of AVMs showed neither postinterventional remnant nor new neurologic signs and symptoms. Complications included 1 postoperative epidural hematoma and 1 vasospasm during endovascular treatment. Treatment of AVMs in the hOR offers the possibility to adapt surgical approaches based on iDSA findings after intraoperative embolization, thus achieving better clinical and radiologic results. Radical treatment of AVMs with low Spetzler-Martin grades by combining endovascular and microsurgical techniques in the hOR was technically feasible, effective, and safe. •Hybrid operations offer a safe and efficient strategy for treatment of symptomatic low-grade AVMs.•Diagnostic intraoperative subtraction angiography may provide relevant information to achieve complete nidal obliteration.•Intraoperative embolization in the hybrid operating room (hOR) may influence subsequent microsurgical strategies.•Radical removal of brain AVMs may be facilitated by a combined approach in the hOR.