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EXPERT COMMENTARY
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 55-57

Musings about surgery for intra-cranial arterio-venous malformations


National Neurosciences Mission, Adarsha Super-Specialty Hospital, Manipal-Udupi, Karnataka, India

Date of Submission22-Aug-2020
Date of Acceptance03-Sep-2020
Date of Web Publication1-Oct-2020

Correspondence Address:
Dr. A Raja
National Neurosciences Mission, Adarsha Super-Specialty Hospital, Manipal-Udupi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvs.jcvs_15_20

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  Abstract 


Introduction: Neurosurgery has evolved with the times and as with all things with a rich history, there is much to be learnt from experience and much to be re-iterated in the present.
Aims and objectives: To reinforce the key basic points in AVM surgery, for the benefit of all neurosurgeons operating on AVMs.
Materials: Based on personal experience from over he author recollects integral points and principles of the surgical management of intra-cranial arterio-venous malformations (AVMs), highlighting the basic elements such as planning, exposure, equipment use, intra-operative identification, and safe approach, execution and hemostasis.
Conclusion: The success of AVM surgery depends highly on methodical planning and precise execution.

Keywords: Arterio-venous malformations, AVM, surgery, microsurgery


How to cite this article:
Raja A. Musings about surgery for intra-cranial arterio-venous malformations. J Cerebrovasc Sci 2020;8:55-7

How to cite this URL:
Raja A. Musings about surgery for intra-cranial arterio-venous malformations. J Cerebrovasc Sci [serial online] 2020 [cited 2020 Nov 28];8:55-7. Available from: http://www.jcvs.com/text.asp?2020/8/1/55/296921



With advancement in technology and developments in neurosurgery, the present-day neurosurgeon may not have the opportunity or the exposure to surgery for arterio-venous malformations (AVM) of the brain and spinal cord.[1],[2],[3]

Since I studied at a time when microsurgery in India was at its infancy and interventional techniques had not evolved completely, I had the opportunity of witnessing AVM surgeries[4],[5],[6],[7],[8] without a microscope, and the good fortune to operate with a microscope, on around 100 cases of cranial AVM, which included 13 posterior fossa AVM. I learnt a lot from whatever I had seen as an assistant surgeon as well as an operating surgeon, which I have attempted to recollect here.


  Proper Planning Top


Before embarking on surgery, one needs to study the angiograms in detail to get an idea about the major feeding vessels and draining vessels, which helps to avoid accidents during surgery. As a policy, it is better that the operating surgeon carries out the investigation himself/herself. If fortunate enough to have an interested radiologist, his/her presence during the angiography and advice on appropriate pictures to be studied could aid in obtaining a comprehensive idea about the malformation.


  Adequate Exposure Top


I have always insisted on turning an adequate flap. One may err on the side of a larger flap, but it is better than turning a smaller flap which may hinder the approach to the feeding vessels.


  Verifying Equipment Top


A good suction is very important. One must make sure of the availability of at least two properly working suction apparatus, preferably with nozzles with keyhole thumb control and the ability to increase or decrease the suction pressure.


  Practical Tip to Avoid Complications Top


Though it may appear trivial – some of these steps described have been very helpful in avoiding problems.

It is very important to keep instruments well inside the instrument table, to prevent inadvertent slippage of the instruments on to the operative field, which may be catastrophic.


  Bipolar Forceps Top


It is preferable to have one forceps with a tip of 2 mm which can be of use to coagulate thin-walled veins before they are divided.


  Availability of Temporary Clips and Smaller Weck Clips Top


It is always advisable and advantageous to have temporary clips, both regular ones and mini clips, with the appropriate applicators. Applying temporary clips before permanent clipping or dividing helps in identifying feeder vessels. Weck clips are useful in clipping the vessels in addition to bipolar coagulation as, at times, the coagulated vessel may open up and result in torrential haemorrhages and hence after coagulation, it is better to apply these haemostatic clips and divide between two clips. I have not had the necessity to use hypotension in operating on these malformations and my preference has been to maintain the blood pressure within the normal range.


  Proximal Control of Feeders Top


After adequate exposure with a microscope, the proximal feeders have to be identified to confirm that they are feeding the lesion. Temporary aneurysm clip application may be helpful, but one has to bear in mind that putting a clip on a single vessel will make the malformation either less pulsatile or will make the circulating blood change colour. At times, more than two/three vessels may have to be clipped and one has to wait, and see. One must remember that a malformation may get blood supply from different vessels situated at different points and all may not be in the same area. It is not practical to apply temporary occlusion to all vessels, so, after applying temporary clips, one has to look for changes in the venous flow in the nearby vessels and decrease in turgidity of the lesion. If this happens, one may go ahead in coagulating/clipping and dividing the vessel. In smaller malformations, this step is relatively easier.


  Approaching the Malformation Top


In many of these cases, if there had been previous bleed with glial changes, the glial plane will be the safe bet. Usually, malformations may be associated with some atrophy of the adjoining brain and there will be dilation of the sulci. These provide good entry points to the malformation, and slowly one must go in a circumferential manner to identify the arterial feeder to be occluded.


  Feeder Clipping Top


While clipping the feeder, one has to go as near the malformation as possible, to avoid occluding the feeder from which the branches supplying the normal brain may arise. Though it is classically described in all operative surgery texts, practically, it is a difficult task. Now, with intraoperative indocyanine green angiography, things have been made easier.[9],[10]


  Dissection Top


The presence of underlying haematoma was considered advantageous, and it is supposed to dissect the malformation from its bed. One should not be carried away by this statement and think that after the surface dissection of feeders, and after entering the haematoma, the malformation will come off. It does not happen. When one goes through the haematoma, there are multiple fine as well as medium-sized vessels which arise from the underlying brain. These have to be coagulated and divided, or they might lead to a troublesome bed haematoma. Thus, till the last of these vessels are coagulated and divided, one cannot be complacent in AVM surgery.[4],[5],[7],[8]


  Dealing With the Veins Top


Though it is said that it is better to leave the draining veins intact till the end, it is practically not possible to leave all the veins. One has to choose two or three large veins which are superficially placed to preserve, and take the other vessels and go around dissecting, or it may not be possible to proceed with the removal of the lesion. It is safer to divide the vessels where the normal arterial wall is seen rather than in the malformation where it is very difficult to coagulate the abnormal walled vessel.

Though it is said that malformations situated in the non-dominant frontal or temporal pole are easier to remove, nothing can be taken for granted. Some of these malformations may have drainage to the deep venous system or may have feeders and draining veins towards the basal dura. Unless one is careful in anticipating and controlling these vessels, rupture of this may lead to catastrophe.

In a nutshell, the successful surgery for these malformations[4],[5],[6] has to involve meticulous planning and a methodical, painstaking, step-by-step surgical approach. One has to remember that once we embark upon surgery, there is no retracting, or turning back. Unlike in tumour surgeries where one may choose to go in for a total excision at a later date, here, there is no such option, and hence right from the first to the final step, it has to be a well-thought-of and well-planned procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Drake CG. Cerebral arteriovenous malformations: Considerations for and experience with surgical treatment in 166 cases. Clin Neurosurg 1979;26:145.  Back to cited text no. 1
    
2.
Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg 1986;65:476-83.  Back to cited text no. 2
    
3.
Crawford PM, West CR, Chadwick DW, Shaw MD. Arteriovenous malformations of the brain: Natural history in unoperated patients. J Neurol Neurosurg Psychiatry 1986;49:1-10.  Back to cited text no. 3
    
4.
Yasargil MG. Microsurgery applied to neurosurgery. Stuttgart, Georg Thieme. 1969. p.105-19.  Back to cited text no. 4
    
5.
Hernesniemi J, Romani R, Lehecka M, Isarakul P, Dashti R, Celik Ö, et al. Present state of microneurosurgery of cerebral arteriovenous malformations. In: Surgical Management of Cerebrovascular Disease. Vienna: Springer; 2010. p. 71-6.  Back to cited text no. 5
    
6.
Davidson AS, Morgan MK. How safe is arteriovenous malformation surgery? A prospective, observational study of surgery as first-line treatment for brain arteriovenous malformations. Neurosurgery 2010;66:498-505.  Back to cited text no. 6
    
7.
Zhao J, Wang S, Li J, Qi W, Sui D, Zhao Y. Clinical characteristics and surgical results of patients with cerebral arteriovenous malformations. Surg Neurol 2005;63:156-61.  Back to cited text no. 7
    
8.
Hashimoto N, Nozaki K, Takagi Y, Kikuta KI, Mikuni N. Surgery of cerebral arteriovenous malformations. Neurosurgery 2007;61(suppl_1):SHC-375.  Back to cited text no. 8
    
9.
Killory BD, Nakaji P, Gonzales LF, Ponce FA, Wait SD, Spetzler RF. Prospective evaluation of surgical microscope–integrated intraoperative near-infrared indocyanine green angiography during cerebral arteriovenous malformation surgery. Neurosurgery 2009;65:456-62.  Back to cited text no. 9
    
10.
Zaidi HA, Abla AA, Nakaji P, Chowdhry SA, Albuquerque FC, Spetzler RF. Indocyanine green angiography in the surgical management of cerebral arteriovenous malformations: Lessons learned in 130 consecutive cases. Neurosurgery 2014;10 (Suppl 2):246-51.  Back to cited text no. 10
    




 

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  In this article
Abstract
Proper Planning
Adequate Exposure
Verifying Equipment
Practical Tip to...
Bipolar Forceps
Availability of ...
Proximal Control...
Approaching the ...
Feeder Clipping
Dissection
Dealing With the...
References

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