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microsurgery for vascular malformations of the brain

Microsurgery constitutes the most effective and robust treatments for brain arteriovenous malformations so long as the nidus can be safely accessed. In this section the general principles applied when surgically approaching an AVM are described. These lesions vary greatly in their architecture, size and complexity so the surgery must be meticulously planned to get the desired result. The potential complications vary from one case to another and the surgeon will endevour to describe the particular risk-profile of a procedure on a case by case basis after careful review of the cross sectional imaging and angiograms.

Surgery may be combined with other therapies, most commonly endovascular treatment of the malformation but radiosurgery has also been used to target very large AVMs to render them safer surgical prospects. Endovascular embolisation is described in more detail elsewhere on the site. It use as an adjunct to surgery is usually reserved for larger lesions with a high blood flow.

 

Preparing for Surgery.

It is usually the case that a patient undergoing microsurgery for an AVM will undego a pre-Image guided neurosurgeryoperative CT or MR scan which is fed into a computer guidance system that helps to precisely direct the surgeon to the area in the brain being targetted. During the procedure various tools may be deployed to demonstrate the architecture of the malformation and ultimately to help demonstrate that the malformation has been completely removed. These tools include ultrasound scans of the brain, indocyanine green videoangiography and intraoperative digital subtraction angiography.

Admission to the intensive care or high dependency units will be planned ahead of surgery. Larger AVMs will sometimes require long procedures and during general anesthesia great care is given to control of the patients blood pressure and this control is maintained on the intensive care unit in the immediate post-operative period. Anti-epileptic medication may be prescribed for a period of time after the surgery even if seizures have not occurred up to that point. Blood will be taken to cross match in case blood transfusion is required during the operation as is occasionally required.

The surgeon will discuss the risks of the procedure and try to address any questions a patient or their carers have before . They will complete a consent form with you documenting the reasons the procedure is being undertaken, the estimated risks of the operation and outlining what the folow up will be afterwards. Signing of the form is a necessary formality which does not mean more questions cannot be posed or indeed that a patient may not change their mind. You will be provided a copy of the consent form and with copies of clinical correspondence.

Grading systems for arteriovenous malfomormations are tools which assist in the estimation of surgical risk as well as the suitability of an AVM for various modes of treatment. The ones we commonly utilise are the Spetzler-Martin, Spetzler-Ponce and Lawton-Young Supplemental grades. A similar system in use for radiosurgical planning is the Pollock-Flickinger scores. Such scoring systems help inform but do not replace clinical judgement in deciding what treatment is appropriate.


During the surgery.

Temporal lobe AVM Temporal AVM partly dissected
AVM completely mobilised before division of draining vein AVM nidus after removal
A: AVM in temporal lobe cortex B: Nidus partly dissected but still with blood flow
C: The nidus is now disconnected from arterial supply and veins have collapsed D: The nidus after removal.

The surgical strategy is to sequentially disconnect the arteries supplying blood to the nidus of the AVM. Gradually the blood flow is abolished throughout the nidus and the veins draining blood away from it collapse. This is illustrated in the series of images on the right. This patient has an arteriovenous malformation in the temporal lobe. The nidus is gently dissected away from the normal cerebral cortex. The arteries are then sequentially disconnected. There are a few large arteries which are closed with the aid of clips and many tiny blood vessels joining the nidus from the surrounding brain. Not until all arteries are disconnected do the nidus, and the veins draining blood from it, change from engorged pink vessels to soft, blue ones. This indicates the abnormal connection from arterial circulation to venous has been abolished and that the nidus may be safely lifted away from the brain with division of the last vein. A further angiogram is carried out to confirm complete removal of the AVM.

For large, AVMs with a high blood flow routine admission to high dependency or intensive care per-operatively is arranged. Very strict control is maintained over the patients blood pressure until an angiogram has confirmed the absence of any residual arteriovenous shunting of blood.

Successful treatment of larger AVMs involves multidiciplinary, staged procedures on occasion. The various members of the multidiciplinary team will be happy to answer questions on its various parts.