Strategy for the treatment of arteriovenous malformations

• Published in: Journal of clinical neuroscience 2000-09, Vol.7, p.60-68
• Main Authors: Sano, Hirotoshi, Kato, Yoko, Bannur, Uma, Okuma, Isao, Kanaoka, Narimasu, Kanno, Tetsuo
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; AVM, eloquent cortex, minimally invasive surgery; Combined Modality Therapy; Embolization, Therapeutic; Female; Humans; Intracranial Arteriovenous Malformations - diagnostic imaging; Intracranial Arteriovenous Malformations - therapy; Male; Middle Aged; Minimally Invasive Surgical Procedures - instrumentation; Minimally Invasive Surgical Procedures - methods; Radiography; Surgical Instruments; Tomography, Emission-Computed, Single-Photon; Treatment Outcome; Vascular Surgical Procedures - instrumentation; Vascular Surgical Procedures - methods
• ISSN: 0967-5868; 1532-2653
• DOI: 10.1054/jocn.2000.0714

The treatment of arteriovenous malformations (AVMs) is still a challenging problem in the neurosurgical field. The deep-seated AVMs are a definite indication for radiosurgery for the small AVMs and with pre-embolisation for the large AVMs. The superficial AVMs are a good indication for surgery. In the case of small AVMs, surgery alone is a viable option; however, in the case of large AVMs, pre-operative embolisation is essential for prevention of NPPB (normal perfusion pressure breakthrough). Embolisation alone cannot be used, except for a small AVM in the non-eloquent cortex. Preoperative embolisation makes surgery easy; however, it causes the surrounding cortex to infarct. Hyperperfusion may occur after the direct removal of high-flow large AVMs, therefore postoperative management will be difficult in these cases. In eloquent cortex minimally invasive surgery is more reliable with respect to the morbidity produced. Therefore in cases of small AVMs in the functional cortex, direct surgery is the only choice. In cases of high-flow large AVMs, surgery and postoperative management are risky because of NPPB. Therefore pre-operative embolisation followed by surgery is a better choice. In high-flow AVMs, local blood circulation is not decreased by temporary clipping of the feeding arteries. So we recommend temporary clipping of all feeding arteries, even away from the nidus where it is easier to control bleeding.