J Korean Neurosurg Soc.  2021 Nov;64(6):882-890. 10.3340/jkns.2021.0016.

Three-Dimensional Printing Assisted Preoperative Surgical Planning for Cerebral Arteriovenous Malformation

• Uzunoglu I
• Kızmazoglu C
• Husemoglu RB
• Gurkan G
• Uzunoglu C
• Atar M
• Cakır V
• Aydın HE
• Sayın M
• Yuceer N

• KMID: 2521978
• DOI: http://doi.org/10.3340/jkns.2021.0016

Abstract

Objective
: The aim of this study to investigate the benefits of patient-based 3-dimensional (3D) cerebral arteriovenous malformation (AVM) models for preoperative surgical planning and education.
Methods
: Fifteen patients were operated on for AVMs between 2015 and 2019 with patient-based 3D models. Ten patients’ preoperative cranial angiogram screenings were evaluated preoperatively or perioperatively via patient-based 3D models. Two patients needed emergent surgical intervention; their models were solely designed based on their AVMs and used during the operation. However, the other patients who underwent elective surgery had the modeling starting from the skull base. These models were used both preoperatively and perioperatively. The benefits of patients arising from treatment with these models were evaluated via patient files and radiological data.
Results
: Fifteen patients (10 males and five females) between 16 and 66 years underwent surgery. The mean age of the patients was 40.0±14.72. The most frequent symptom patients observed were headaches. Four patients had intracranial bleeding; the symptom of admission was a loss of consciousness. Two patients (13.3%) belonged to Spetzler-Martin (SM) grade I, four (26.7%) belonged to SM grade II, eight (53.3%) belonged to SM grade III, and one (6.7%) belonged to SM grade IV. The mean operation duration was 3.44±0.47 hours. Three patients (20%) developed transient neurologic deficits postoperatively, whereas three other patients died (20%).
Conclusion
: Several technological innovations have emerged in recent years to reduce undesired outcomes and support the surgical team. For example, 3D models have been employed in various surgical procedures in the last decade. The routine usage of patient-based 3D models will not only support better surgical planning and practice, but it will also be useful in educating assistants and explaining the situation to the patient as well.

Keyword

Intracranial arteriovenous malformations; Three-dimensional printing; Spetzler-Martin grade

Figure

• 

  Fig. 1. A : Preoperative digital subtraction angiography image of 26 years female patient with feeding arteries from right medial cerebral artery and anterior cerebral artery. b : Anterior view of 3-dimensional solid in stereolithography format. c : Postoperative brain computed tomography of the patient.

• 

  Fig. 2. Superior (A), superior anterior (b), anterior (c), and lateral (d) view of the printed brain arteriovenous malformation model with the skull (patient 1). A1, A2, and A3 mean anterior cerebral artery branches. M1, M2, M3, and M4 mean middle cerebral artery branches. IcA : internal carotid artery.

• 

  Fig. 3. A : Preoperative digital subtraction angiography image of 38 years female patient with feeding arteries from left medial cerebral artery. b and c : Anterior-posterior view of 3-dimensional solid in stereolithography format. d : Postoperative brain computed tomography of the patient.

• 

  Fig. 4. Superior (A), anterior (b), lateral (c), and posterior (d) view of the printed brain arteriovenous malformation model with the skull (patient 2). M1, M2, and M3 mean middle cerebral artery branches. IcA : internal carotid artery.

• 

  Fig. 5. A : Preoperative digital subtraction angiography image of 28 years male patient with feeding arteries from left superior cerebellar artery and posterior inferior cerebellar artery. b : Anterior view of 3-dimensional solid in stereolithography format. c : Postoperative brain computed tomography of the patient.

• 

  Fig. 6. Superior- posterior (A), posterior (b), superior-anterior (c), and lateral (d) view of the printed brain arteriovenous malformation model with the skull (patient 3). bA : basilar artery, ScA : superior cerebellar artery, PIcA : posterior inferior cerebellar artery.

Reference

References

1. Bervini D, Morgan MK, Ritson EA, Heller G. Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. J Neurosurg. 121:878–890. 2014.

2. Burlakoti A, Kumaratilake J, Taylor J, Massy-Westropp N, Henneberg M. The cerebral basal arterial network: morphometry of inflow and outflow components. J Anat. 230:833–841. 2017.

3. Davies JM, Yanamadala V, Lawton MT. Comparative effectiveness of treatments for cerebral arteriovenous malformations: trends in nationwide outcomes from 2000 to 2009. Neurosurg Focus. 33:E11. 2012.

4. Grüter BE, Mendelowitsch I, Diepers M, Remonda L, Fandino J, Marbacher S. Combined endovascular and microsurgical treatment of arteriovenous malformations in the hybrid operating room. World Neurosurg. 117:e204–e214. 2018.

5. Gunnal S, Farooqui M, Wabale R. Anatomical variability in the termination of the basilar artery in the human cadaveric brain. Turk Neurosurg. 25:586–594. 2015.

6. Heros RC, Tu YK. Unruptured arteriovenous malformations: a dilemma in surgical decision making. Clin Neurosurg. 33:187–236. 1986.

7. Jean WC, Huynh T, Tai AX, Felbaum DR, Syed HR, Ngo HM. Outcome of microsurgery for arteriovenous malformations in a resource-restricted environment: single-surgeon series from vietnam. World Neurosurg. 132:e66–e75. 2019.

8. Lawton MT, Du R, Tran MN, Achrol AS, McCulloch CE, Johnston SC, et al. Effect of presenting hemorrhage on outcome after microsurgical resection of brain arteriovenous malformations. Neurosurgery. 56:485–493. discussion 485-493. 2005.

9. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 366:809–817. 2005.

10. Potts MB, Lau D, Abla AA, Kim H, Young WL, Lawton MT, et al. Current surgical results with low-grade brain arteriovenous malformations. J Neurosurg. 122:912–920. 2015.

11. Rhoton AL Jr. The supratentorial cranial space: microsurgical anatomy and surgical approaches. Neurosurgery. 51:S1-iii–S1-vi. 2002.

12. Schramm J, Schaller K, Esche J, Boström A. Microsurgery for cerebral arteriovenous malformations: subgroup outcomes in a consecutive series of 288 cases. J Neurosurg. 126:1056–1063. 2017.

13. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 65:476–483. 1986.

14. Starke RM, Komotar RJ, Hwang BY, Fischer LE, Garrett MC, Otten ML, et al. Treatment guidelines for cerebral arteriovenous malformation microsurgery. Br J Neurosurg. 23:376–386. 2009.

15. Thawani JP, Pisapia JM, Singh N, Petrov D, Schuster JM, Hurst RW, et al. Three-dimensional printed modeling of an arteriovenous malformation including blood flow. World Neurosurg. 90:675–683.e2. 2016.

16. Theofanis T, Chalouhi N, Dalyai R, Starke RM, Jabbour P, Rosenwasser RH, et al. Microsurgery for cerebral arteriovenous malformations: postoperative outcomes and predictors of complications in 264 cases. Neurosurg Focus. 37:E10. 2014.

17. Tong X, Wu J, Cao Y, Zhao Y, Wang S, Zhao J. Microsurgical outcome of unruptured brain arteriovenous malformations: a single-center experience. World Neurosurg. 99:644–655. 2017.

18. von der Brelie C, Simon M, Esche J, Schramm J, Boström A. Seizure outcomes in patients with surgically treated cerebral arteriovenous malformations. Neurosurgery. 77:762–768. 2015.

19. Weinstock P, Prabhu SP, Flynn K, Orbach DB, Smith E. Optimizing cerebrovascular surgical and endovascular procedures in children via personalized 3D printing. J Neurosurg Pediatr. 16:584–589. 2015.

20. Wong J, Slomovic A, Ibrahim G, Radovanovic I, Tymianski M. Microsurgery for ARUBA trial (a randomized trial of unruptured brain arteriovenous malformation)-eligible unruptured brain arteriovenous malformations. Stroke. 48:136–144. 2017.