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Trans-radial artery microcatheter angiography-assisted juvenile ruptured brainstem arteriovenous malformation resection

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Abstract

Background

Due to their crucial functional location, surgical treatment of brainstem arteriovenous malformations (AVMs) has always been challenging. For unruptured AVMs, we can determine whether radiological therapy, interventional treatment, or surgical resection is feasible based on the AVM structure. However, for ruptured AVMs, microsurgical resection and interventional embolization are effective methods to prevent further rupture. In the microsurgical resection of AVMs, we usually use a hybrid operation to confirm the AVM structure and determine if the AVM is completely resected during the surgery.

Method

We report a case of juvenile ruptured brainstem AVM resection. The right lateral position and left suboccipital retrosigmoid approach were used. We established an interventional approach via left radial artery and set a microcatheter in the feeding artery. Methylene blue injection via a microcatheter showed the AVM structure, and we totally resected the brainstem AVM under electrophysiological monitoring and navigation. Intraoperative angiography was performed to ensure complete resection without residual nidus.

Conclusion

This case demonstrates that the trans-radial approach is convenient and safe for special positions in hybrid operations. Methylene blue injection via a microcatheter in the feeding artery provides clearer visualization of the AVM structure under the microscope.

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References

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Funding

This study was supported by the Clinical Research Plan of SHDC (No. SHDC2020CR2034B to WZ) and the Special Clinical Research Project in Health Industry of Shanghai Municipal Health Commission (No. 20224Y0072 to PL).

Author information

Author notes

  1. Peixi Liu and Hongfei Zhang contributed to this article equally.

Authors and Affiliations

  1. Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, No. 12 Wulumuqi Zhong Road, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Tianming Qiu & Wei Zhu

  2. National Center for Neurological Disorders, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Tianming Qiu & Wei Zhu

  3. Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Tianming Qiu & Wei Zhu

  4. Neurosurgical Institute of Fudan University, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Tianming Qiu & Wei Zhu

  5. Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China

    Peixi Liu, Hongfei Zhang, Tianming Qiu & Wei Zhu

Authors
  1. Peixi Liu
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  2. Hongfei Zhang
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  3. Tianming Qiu
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  4. Wei Zhu
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Contributions

Peixi Liu: participation in surgery, conception, and design of study, provision of study material, collection and/or assembly of data, manuscript writing, and final approval of manuscript.

Hongfei Zhang: literature collection and collation.

Tianming Qiu: participation in surgery, conception, and design of study.

Wei Zhu: conception and design of the study and revision and final approval of the manuscript.

Corresponding author

Correspondence to Tianming Qiu.

Ethics declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Huashan Hospital Institutional Review Board (HIRB), Fudan University, Shanghai, China.

Consent to participate

The patient gave approval for this publication.

Conflict of interest

The authors declare no competing interests.

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Key points

1. Juvenile ruptured brain stem AVMs should be treated as early as possible to prevent rebleeding.

2. Radiological therapy is an optional choice but has a slow onset. The benefit/risk balance for the treatment strategy should be taken into consideration.

3. Intraoperative DSA ensures AVM total resection.

4. The TRA approach in the hybrid operation is convenient in the prone, lateral decubitus, and lateral oblique positions. The Allen test before the operation is crucial for ulnar artery compensation.

5. TRA sheath saline infusion must be maintained to avoid thrombosis complications.

6. Methylene blue injection clearly demonstrated the AVM structure. It provided more accuracy and short time repeatability than routinely used ICG injection.

7. SSEP, MEP, and cranial nerve monitoring are quick measures to determine functional protection.

8. Postoperative nasal intubation and delayed removal are needed. The white card test is needed before intubation removal.

9. If needed, jejunal tube placement in the early stage could avoid posterior cranial nerve-induced dysphagia complications.

10. Early-stage habitation therapy is needed.

Supplementary Information

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Liu, P., Zhang, H., Qiu, T. et al. Trans-radial artery microcatheter angiography-assisted juvenile ruptured brainstem arteriovenous malformation resection. Acta Neurochir 166, 53 (2024). https://doi.org/10.1007/s00701-024-05915-4

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