Surgical Management of Large Cerebral Arteriovenous Malformation

Yim, Man Bin

Abstract

OBJECTS: The surgical management of large cerebral arteriovenous malformation(AVM) is still one of the most difficult fields in neurosurgery. To select the proper candiate for the surgery and improve the results of surgical management of large AVMs, the analysis of the author's cases and the review of the literstures are performed. METERIAL AND METHODS: During the past 17 years, 111 patients with cerebral AVMs were managed surgically. Among these cases, 23 patients had the large AVMs, more than 5 cm in the greatest diameter. The author analyzes these 23 cases clinically and discusses the natural history, surgical indication, surgical techniques, intraoperative and postoperative complications and their management on the basis of the author's experiences and a review of the literatures.
RESULTS
Among 23 cases, 16 cases showed good outcome without any neurological morbidity. 6 cases showed mild neurological morbidity such as a memory disturbance, mild hemiparesis or unchanged patterns of seizure, and 1 case showed dense hemiplegia after surgery. There was no mortality. The surgical management of the large AVMs should be decided very carefully because their natural history is relatively benign. An early arterial phase of an angiogram is very useful in discriminating feeders from nidus. An intraoperative use of Doppler ultrasound miniature probe is useful for making a distinction between feeding arteries and drain veins. Wide opening of the fissures and sulci and follows the feeding arteries to the nidus, removing the nidus along the exact border to the brain, induced hypotension during operation and postoperative period with or without pentothal coma were the key points for the surgical management of large AVMs.
CONCLUSION
The surgical management of large AVMs is so difficult that the candidates for surgery should be selected carefully bases on the characteristics of the AVMs and experiences of surgeons. However, with experience and meticulous attention, many of these lesions can be resected without development of any morbidity and mortality.