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Abstract
To assess the importance of pre-operative embolisation, 27 cases of cerebral artriovenous
malformation (AVM) treated in this institute between July 1994 and October 1998 were
analysed. The patients’ ages ranged from 3 to 70 years (average 36.9) with a follow-up
period of 1–41 months (average 19.2). The patient presented with haemorrhage in 21
cases and seizure in five. In 21 of 27 cases, surgical resection of a nidus was performed,
gamma knife therapy was applied in three and conservative therapy was chosen in three.
Of 21 cases treated surgically, total removal was achieved in 19 cases and a residual
nidus was seen in one (a large basal ganglia AVM). In the remaining case, postoperative
angiography was not available. Pre-operative embolisation followed by surgical resection
of the nidus was performed in seven cases in which there was a large AVM. A volume
index was calculated to indicate the size of the nidus using X × Y × Z, where X is
the maximum diameter (cm) of the nidus on the lateral angiogram, Y is the diameter
(cm) perpendicular to X and Z is the maximum diameter (cm) on the anteroposter or
angiogram. The index averaged 45.9 for the cases in which pre-operative embolisation
was performed, while it was 5.6 in the cases without embolisation. Pre-operative embolisation
was performed to reduce the nidus flow as much as possible, to prevent overload to
the surrounding structures. At surgery, the nidus was resected from the surrounding
tissue and care was taken not to enter the nidus. Postoperatively, the systolic blood
pressure was maintained at 90–100 mmHg for several days in the intensive care unit.
The results were excellent in 15 cases, good in three (hemiparesis due to the initial
haemorrhage remained in all three), fair in one (a patient with a severe subarachnoid
haemorrhage). Two patients died (acute pulmonary oedema and severe meningitis). Minor
postoperative bleeding or oozing was seen in three cases. In conclusion, reducing
the shunt flow through a nidus in a step-wise fashion with pre-operative embolisation
of a large AVM seems to be quite helpful in preventing postoperative haemodynamic
overload to the surrounding brain. It is also important not to enter the nidus when
it is removed at surgery. This helps to prevent intraoperative and/or postoperative
bleeding, and led to successful total removal of the nidus with a good postoperative
course.
Keywords
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© 2000 Published by Elsevier Inc. All rights reserved.
