gms | German Medical Science

Objective: The surgical resection of cerebral arteriovenous malformations (AVMs) may be associated with significant morbidity and mortality depending on the location and size of the lesion and vascular architecture according to the Spetzler-Martin-grade. AVMs with succinct feeding arteries may undergo endovascular embolization before surgical resection. Stepwise endovascular devascularisation of the AVMs may lead to increasing safety of the surgical procedure.

Method: From January 2006 to June 2010, 27 patients underwent surgical resection of an intracerebral AVM. Among them, 16 patients had previous endovascular embolization before surgery. The mean age of the patients was 40 years (range of 11–72 years). Preoperative embolization was performed when at least parts of the AVM were supplied through an accessible arterial feeder.

Results: Fourteen patients presented with an intracerebral hemorrhage before surgery. AVMs were grades as Spetzler-Martin grade 1 in one patient, grade 2 in 7 patients, grade 3 in 12 patients, grade 4 in 4 patients and grade 5 in 2 patients. 23 AVMs were in the anterior and 4 AVMs in the posterior circulation. Two patients died after surgery. One patient with a grade 4 AVM required second surgery for removal of a remnant AVM. In one patient with a grade 5 AVM, in whom previous embolization could not be performed, postoperative hemorhage and brain edema required surgical decompression. Among 11 patients without previous embolization, postoperative Glasgow outcome scale was 5 in 8 patients, 4 and 3 in 1 patient each and 1 in 1 patient. In 16 patients with preoperative embolization, postoperative outcome was Glasgow outcome sclale 5 in 12 patients, 4 in 1 patient, 3 in 1 patient and 1 in 2 patients. In patients with large AVMs the clinical outcome was excellent when partial or subtotal embolization could be performed before surgery. In small to medium-size AVMs excellent results could be obtained even when embolization was not possible preoperatively.

Conclusions: Patients with large AVMs may benefit from preoperative embolization, when feeding vessels may be safely accessed and occluded through the endovascular route. Even partial or subtotal preoperative endovascular occlusion of the AVM may result in increasing safety and less blood loss during microsurgical removal. In small to medium-size AVMs the benefit of preoperative embolization needs to be further investigated.