Summary
Patients and techniques
A series of 67 patients treated for cerebral AVMs with a multidisciplinary approach is reported, with special attention for the complications due to treatment. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% highgrade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery (30%), either alone or after embolization or surgery. The following eradication rates were obtained: overall 80%, after resection (with or without embolization) 91%, after embolization alone 13%, after radiosurgery 87%.
Clinical outcome
The outcome was evaluated in terms of deterioration due to treatment. A deterioration after treatment occurred in 19 patients (28%), and was a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was responsible for deterioration (minor) in 17% of all cases operated upon. Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization gave a complication in 25% of all embolized cases (minor or neurological deficit, or death). The mechanism of the complications was: resection or manipulation of an eloquent area during surgery, radionecrosis after radiosurgery, ischaemia and haemorrhage (50% each) following embolization. In most cases of haemorrhage due to embolization, occlusion of the main venous drainage could be demonstrated.
Discussion
The haemodynamic disturbances to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms admitted at the beginning of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, the disturbances of the venous drainage (venous overload or occlusive hyperaemia), and the retrograde thrombosis of the feeding arteries.
Conclusions
According the authors' experience, the emphasis of treatment for cerebral AVMs has now shifted from surgical resection to endovascular embolization. One of the explanations is that endovascular techniques are now employed in the most difficult cases (high grade AVMs). As severe complications of endovascular embolization may also occur for low-grade malformations, the question arises whether surgery or radiosurgery should not be used first for this low-grade group even if embolization is feasible.
Similar content being viewed by others
References
Al Rhodan NRF, Sundt ThM, Jr, Piepgras DG, Nichols DA, Rufenacht D, Stevens LN (1993) Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral AVMs. J Neurosurg 78: 167–175
Ancri D, Pertuiset B (1985) Mesures des vitesses sanguines instantanées dans les artères carotides internes par Doppler puisé dans les MAV cérébrales. Neurochirurgie 31: 1–6
Awad JA, Magdinec M, Schubert A (1994) Intracranial hypertension after resection of cerebral arteriovenous malformations. Predisposing factors and management strategy. Stroke 25: 611–620
Barnett GH, Little JR, Ebrahim ZY, Jones SC, Friel HT (1987) Cerebral circulation during AVM operation. Neurosurgery 20: 836–842
Batjer HM, Devous MD, Meyer YJ, Purdy PD, Samson DS (1988) Cerebrovascular hemodynamics in AVM complicated by normal perfusion pressure breakthrough. Neurosurgery 22: 503–509
Batjer HM, Devous MD, Devous SR, Seibert GB, Purdy PD, Ajmani AK, Delarosa M, Bonte J (1988) Intracranial AVMs. Relationship between clinical and radiographic factors and ipsilateral steal severity. Neurosurgery 23: 322–328
Batjer HM, Purdy PD, Giller CA, Samson DS (1989) Evidence of redistribution of cerebral blood flow during treatment for an intracranial AVM. Neurosurgery 25: 599–605
Batjer HM, Devous MD (1992) The use of acetazolamine. Enhanced regional cerebral blood flow measurement to predict risk to AVM patients. Neurosurgery 31: 213–218
Bonnal J, Born JD, Hans P (1985) One-stage excision of highflow arterio-venous malformation. J Neurosurg 62: 128–131
Day AL, Friedman WA, Sypert GW, Mickl JP (1982) Successful treatment of the normal perfusion pressure breakthrough syndrome. Neurosurgery 11: 625–630
Deruty R, Pelissou-Guyotat I, Mottolese C, Bascoulergue Y, Amat D (1993) The combined management of cerebral arteriovenous malformations (experience with 100 cases and review of the literature). Acta Neurochir (Wien) 123: 101–112
Hassler W, Steimetz H (1987) Cerebral hemodynamics in angioma patients: an intra operative study. J Neurosurg 67: 822–831
Heros RC (1987) Comments on: cerebral circulation during arteriovenous malformation operation, by Barnett GH, Little Jr, Ebrahim ZY, Jones SC, Friel HT. Neurosurgery 20: 841
Jafar JJ, Davis AJ, Berenstein A, Choi IS, Kupersmith MJ (1993) The effect of embolization with N-butylcyanoacrylate prior to surgical resection of cerebral AVMs. J Neurosurg 78: 60–69
Leblanc R, Little JR (1988) Hemodynamics of arteriovenous malformations. Clin Neurosurg 36: 299–317
Lindegaard KF, Grolimund P, Aaslid R, Nornes H (1986) Evaluation of cerebral AVMs using transcranial Doppler ultrasound. J Neurosurg 65: 335–344
Lo EH (1993) A haemodynamic analysis of intracranial arteriovenous malformations. Neurolog Res 15: 51–55
Manchola JF, De Salles AF, Foo TK, Ackerman AH, Candia GT, Kjelberg RN (1993) AVM hemodynamics: a transcranial Doppler study. Neurosurgery 33: 556–562
Miyasaka H, Yada K, Ohwada T, Kitahara T, Endoh M, Saito M, Kurata A, Ohtaka H (1990) Retrograde thrombosis of feeding arteries after removal or arterial AVMs. J Neurosurg 72: 540–545
Miyasaka H, Yada K, Ohwada T, Kurata A, Tokiwa K, Suwa T, Yamada M, Oka H (1991) Hemorrhagic venous infarction after excision of an AVM. Neurosurgery 29: 265–268.
Morgan MK, Sundt ThM, Jr (1989) The case against staged operative resection of cerebral AVMs. Neurosurgery 25: 429–435
Morgan MK, Johnston IH, Hallinan JM, Weber NC (1993) Complications of surgery of AVMs of the brain. J Neurosurg 78: 176–182
Mullan S, Brown FD, Patronas NJ (1979) Hyperthermic and ischemic problems of surgical treatment of arteriovenous malformations. J Neurosurg 51: 757–764
Musaszko K, Wang HH, Pelton G, Stein BM (1990) A study of the reactivity of feeding vessels to arteriovenous malformations: correlation with clinical outcome. Neurosurgery 26: 190–200
Nagao S, Ueta K, Mino S, Fuhiwara T, Yonma Y, Ito T, Ohmoto T, Ohkawa M (1989) Monitoring of cortical blood flow during excision of AVM by thermal diffusion method. Surg Neurol 32: 137–143
Nornes H, Grip A (1980) Hemodynamic aspects of cerebral arteriovenous malformations. J Neurosurg 53: 456–464
Okabe T, Meyer JS, Okayasu H, Harper R, Rose J, Grossman RG, Centeno R, Tachibana H, Lee YY (1983) Xenon-enhanced CT CBF measurements in cerebral AVMs before and after excision. Contribution to pathogenesis and treatment. J Neurosurg 59: 21–31
Pertuiset B, Ancri D, Sichez JP, Chauvin M, Guilly E, Metzger J, Gardeur D, Basset JY (1983) Radical surgery in cerebral AVMs. Tactical procedure based upon haemodynamic factors. In: Krayenbuchl Het al (eds) Advances and technical standards in neurosurgery, vol 10. Springer, Wien New York, pp 81–146
Pertuiset B, Ancri D, Mahdi M, Nakano H, Arthuis F, Bagnat-Guilly E (1990) A new haemodynamic factor in cerberal AVMs: aspiration from the venous system demonstrated in two cases of pedonculo-galen AVM successfully cured by occlusion of the superior longitudinal sinus. Acta Neurochir (Wien) 104: 136–142
Rosenblum BR, Bonner RF, Oldfield EH (1987) Intra operative measurement of cortical blood flow adjacent to cerebral AVM using laser Doppler velocimetry. J Neurosurg 66: 396–399
Spetzler RF, Wilson CB, Weinstein PH, Mehdorn M, Town-send JJ, Telles D (1977) Normal perfusion pressure breakthrough theory. Clin Neurosurg 25: 651–672
Spetzler RF, Hargraves RW, Mc Cormick PW, Zabramski JM, Flom RA, Zimmerman RS (1992) Relationship of perfusion pressure and size to risk of hemorrhage from AVMs. J Neurosurg 76: 918–923
Sugita M, Takahashi A, Ogawa A, Yoshimoto T (1993) Improvement of CBF and clinical symptoms associated with embolization of a large AVM. Neurosurgery 33: 748–752
Sundt ThM, Jr, Piepgras DG, Stevens LN (1989) Surgery for supratentorial AVMs. Clin Neurosurg 37: 49–115
Tamaki N, Lin T, Asada M, Fujita K, Tominaga S, Kimura M, Ehara K, Matsumoto S (1990) Modulation of blood flow following excision of a high-flow cerebral AVM. J Neurosurg 72: 509–512
Tamaki N, Ehara K, Fujita K, Shirakuni T, Asada M, Yamashita H (1993) Cerebral hyperfusion during surgical resection of high-flow AVMs. Surg Neurol 40: 10–15
Takeuchi S, Abe H, Nishimaki K, Minakawa T, Koike T, Kameyama S, Tanaka R (1994) Cerebral haemodynamic changes after endovascular treatment of arteriovenous malformations: evaluation by Single-Photon. Emission CT. Acta Neurochir (Wien) 127: 142–150
Tanaka K, Yonekawa Y, Kaku Y, Kazekawa K (1993) Arteriovenous malformations and diaschisis. Acta Neurochir (Wien) 120: 26–32
Taneda M, Mayakawa T (1993) The paradoxical blood pressure-flow relationship in the brain with an AVM. Surg Neurol 40: 390–394
Wilson CB, Hieshima G (1993) Occlusive hyperemia: a new way to think about an old problem. J Neurosurg 78: 165–166
Yamada S (1982) Arteriovenous malformations in the functional areas: surgical treatment and regional cerebral blood flow. Neurol Res 4: 283–322
Young WL, Solomon RA, Prohovnik I, Ornstein E, Weinstein J, Stein BJ (1988) 133Xe Blood monitoring during AVM resection. A case of intra operative hyperperfusion with subsequent brain swelling. Neurosurgery 22: 765–769
Young WL, Prohovnik I, Ornstein E, Ostapkovich N, Sisti MB, Solomon RA, Stein BM (1990). The effect of AVM resection on cerebrovascular reactivity to carbondioxide. Neurosurgery 27: 257–267
Young WL, Kader E, Prohovnik I, Ornstein E, Fleischer LH, Ostapkovitch N, Jackson LD, Stein BM (1993) Pressure autoregulation is intact after AVM resection. Neurosurgery 32: 491–497
Young WL, Pile-Spellman J, Prohovnik I, Kader A, Stein BM (1994) Evidence for adaptive autoregulatory displacement in hypotensive cortical territories adjacent to arteriovenous malformations. Neurosurgery 34: 601–611
Zabramski JM, Spetzler RF (1989) Comments on: the case against staged operative resection of cerebral arteriovenous malformations. In: Morgan MK, Sundt ThM Jr (eds) Neurosurgery 25: 436
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Deruty, R., Pelissou-Guyotat, I., Amat, D. et al. Complications after multidisciplinary treatment of cerebral arteriovenous malformations. Acta neurochir 138, 119–131 (1996). https://doi.org/10.1007/BF01411350
Issue Date:
DOI: https://doi.org/10.1007/BF01411350